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Combining open and endovascular surgery for the treatment of infrarenal abdominal aortic aneurysm: A case report using a hybrid vascular graft

2005; Elsevier BV; Volume: 41; Issue: 5 Linguagem: Inglês

10.1016/j.jvs.2005.02.032

1097-6809

Judith C. Lin, Ralf Kolvenbach, László Pintér,

Infectious Aortic and Vascular Conditions

Migration and endoleaks after endovascular exclusion of an infrarenal abdominal aortic aneurysm may lead to long-term failure of the stent graft. We report a successful case of a novel technique that combined open and endovascular surgery to address the issues of migration and endoleak in the repair of an abdominal aortic aneurysm. The hybrid graft, consisting of a proximal, conventional Dacron graft and two distal endoprosthesis limbs, was designed to reduce aortic cross-clamp time in aortic procedures. This is the first reported clinical experience with this new hybrid vascular graft for the treatment of an abdominal aortic aneurysm. Migration and endoleaks after endovascular exclusion of an infrarenal abdominal aortic aneurysm may lead to long-term failure of the stent graft. We report a successful case of a novel technique that combined open and endovascular surgery to address the issues of migration and endoleak in the repair of an abdominal aortic aneurysm. The hybrid graft, consisting of a proximal, conventional Dacron graft and two distal endoprosthesis limbs, was designed to reduce aortic cross-clamp time in aortic procedures. This is the first reported clinical experience with this new hybrid vascular graft for the treatment of an abdominal aortic aneurysm. Compared with open abdominal aortic aneurysm (AAA) repair, endovascular aneurysm repair (EVAR) reduces the operating time, blood transfusions, intensive care stay, and overall length of hospitalization.1Lee W.A. Carter B.S. Upchurch G. Seeger J.M. Huber T.S. Perioperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms in the United States during 2001.J Vasc Surg. 2004; 39: 491-496Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar, 2Moore W.S. Matsumura J.S. Makaroun M.S. Katzen B.T. Deaton D.H. Decker M. et al.Five-year interim comparison of the Guidant bifurcated endograft with open repair of abdominal aortic aneurysm.J Vasc Surg. 2003; 38: 46-55Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 3Arko F.R. Hill B.B. Olcott C. Harris Jr, E.J. Fogarty T.J. Zarins C.K. Endovascular repair reduces early and late morbidity compared to open surgery for abdominal aortic aneurysm.J Endovasc Ther. 2002; 9: 711-718Crossref PubMed Scopus (60) Google Scholar However, the issues of graft migration and endoleak continue to cause concern for the long-term durability of the stent-graft devices.4Dattilo J.B. Brewster D.C. Fan C.M. Geller S.C. Cambria R.P. LaMuraglia G.M. et al.Clinical failures of endovascular abdominal aortic aneurysm repair incidence, causes, and management.J Vasc Surg. 2002; 35: 1137-1144Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar A multivariate analysis of the EUROSTAR data shows three statistically significant risk factors for rupture after EVAR: the last diameter measurement of the aneurysm, midgraft endoleak, and stent-graft migration.5Harris P.L. Vallabhaneni S.R. Desgranges P. Becquemin J.P. van Marrewijk C. Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms the EUROSTAR experience.J Vasc Surg. 2000; 32: 739-749Abstract Full Text Full Text PDF PubMed Scopus (634) Google Scholar Type II endoleak is common after exclusion of infrarenal AAA with various types of stent-graft devices.6Veith F.J. Baum R.A. Ohki T. Amor M. Adiseshiah M. Blankensteijn J.D. et al.Nature and significance of endoleaks and endotension summary of opinions expressed at an international conference.J Vasc Surg. 2002; 35: 1029-1035Abstract Full Text Full Text PDF PubMed Scopus (509) Google Scholar, 7Matsumura J.S. Moore W.S. Clinical consequences of periprosthetic leak after endovascular repair of abdominal aortic aneurysm.J Vasc Surg. 1998; 27: 606-613Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar From the AneuRx Registry, migration of endovascular stent graft is still an issue.8Zarins C.K. AneuRx Clinical InvestigatorsThe US AneuRx Clinical Trial 6-year clinical update 2002.J Vasc Surg. 2003; 37: 904-908Abstract Full Text PDF PubMed Google Scholar, 9Conners 3rd, M.S. Sternbergh 3rd, W.C. Carter G. Tonnessen B.H. Yoselevitz M. Money S.R. Endograft migration one to four years after endovascualr abdominal aortic aneurysm repair with the AneuRx device a cautionary note.J Vasc Surg. 2002; 36: 476-484Abstract Full Text PDF PubMed Scopus (159) Google Scholar After 3 years of implantation, aortic neck diameter enlargement is associated with graft migration.10Sonesson B. Malina M. Ivancev K. Lindh M. Lindblad Blunkwall J. Dilatation of the infrarenal aneurysm neck after endovascular exclusion of abdominal aortic aneurysm.J Endovasc Surg. 1998; 5 (??): 195-200Crossref PubMed Scopus (71) Google Scholar, 11Fransen G.A. Vallabhaneni Sr, S.R. van Marrewijk C.J. Laheij R.J. Harris P.L. Buth J. et al.Rupture of infra-renal aortic aneurysm after endovascular repair a series from EUROSTAR registry.Eur J Vasc Endovasc Surg. 2003; 26: 487-493Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar This evidence suggest that graft migration and persistent endoleak are associated with EVAR device failure.11Fransen G.A. Vallabhaneni Sr, S.R. van Marrewijk C.J. Laheij R.J. Harris P.L. Buth J. et al.Rupture of infra-renal aortic aneurysm after endovascular repair a series from EUROSTAR registry.Eur J Vasc Endovasc Surg. 2003; 26: 487-493Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar, 12Schlensak C. Doenst T. Hauer M. Moreno J.B. Uhrmeister P. Spillner G. Beyersdorf F. Serious complications requiring surgical interventions after endoluminal stent graft placement for the treatment of infrarenal aortic aneurysms.J Vasc Surg. 2001; 34: 198-203Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 13Pinter L. Kolvenbach R. Regarding salvage of a difficult situation method for conversion of a failed endograft.J Vasc Surg. 2004; 39: 696Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar The objective of combining open and endovascular technique is to reduce the late development of device migration, eliminate endoleaks and endotension, and thus prolong the durability of the aneurysm repair. The concept of a hybrid prosthesis that combines conventional and endovascular components was first introduced by Ferrari (personal communications) after the experimental work performed at the University of Pisa. We describe a patient with an asymptomatic, infrarenal AAA who was successfully managed with a combination of open and endovascular techniques by using a hybrid vascular graft. A 79-year-old white woman presented with an asymptomatic, 5.4-cm infrarenal AAA. Her medical history included remote myocardial infarction, hypertension, and diabetes mellitus. According to the preoperative computed tomography (CT) scan, she had a short infrarenal aortic neck of 1 cm. The hybrid vascular graft was constructed immediately before the start of the operation. Two limbs of a 16- × 8-mm bifurcated knitted Dacron (DuPont) Hemashield Gold graft (Boston Scientific, Natick, Mass) were cut 1 cm below the bifurcation and sewed to two limbs of the deployed 10- × 50-mm Wallgraft Endoprothesis (Boston Scientific) with 5-0 Prolene (Ethicon) running sutures (Fig 1). A 2-cm-width cuff of Exxcel Soft expanded polytetrafluoroethylene (PTFE) (Boston Scientific) was wrapped around the Dacron stent connection to provide additional reinforcement and prevent excessive suture hole bleeding. A preoperative CT scan was used to select the length of the endoprosthesis, which ended 2 cm proximal to the internal iliac origin. The proximal portion of the Dacron graft was cut during the operation according to visualization so that 4 cm in length remained (Fig 2).Fig 2Intraoperative photograph shows the hybrid vascular graft with proximal Dacron graft and polytetrafluoroethylene (PTFE) cuffs.View Large Image Figure ViewerDownload (PPT) Vertical cut-down of both groins and dissection of the femoral arteries was accomplished. After transverse arteriotomy of bilateral common femoral artery, 12F introducer sheaths of the UNISTEP Plus Delivery System (Boston Scientific) were placed within the vessels and 0.035-inch guidewires advanced under fluoroscopic guidance from both groins. The guidewires were kept below the aortic bifurcation. The operative procedure consisted of a transperitoneal, 7-cm mini-laparotomy for the exposure of the proximal aortic neck. After systemic heparinization, the infrarenal aorta was clamped. The iliac arteries were occluded with 8- × 40-mm percutaneous transluminal angioplasty balloons (Boston Scientific). The aorta was incised longitundially and transected 2 cm below the renal arteries. The backbleeding lumbar and inferior mesenteric arteries (IMA) were closed from within the aneurysm sac. The IMA could be reimplanted if there was any evidence of colonic ischemia. An end-to-end proximal anastomosis that incorporated healthy aortic tissue close to the aortic clamp was completed with 3-0 Prolene running sutures. After the guidewires were advanced, the distal limbs of Wallgraft Endoprothesis were reloaded manually back into the two 12F introducer sheaths. The endografts were pulled over the wire together with the sheaths into both common iliac arteries and released. A 9- × 40-mm balloon catheter (Boston Scientific) was used to ensure complete expansion of the endografts and their Nitinol skeleton. Fluoroscopy time was <10 minutes, and 30 mL of contrast was used. The femoral arteriotomy was closed with interrupted 5-0 Prolene sutures. The bilateral groins were closed with 2-0 Vicryl (Ethicon) sutures, and the skin with staples. Declamping and restoration of blood flow was accomplished after 24 minutes. Total operating time was 90 minutes, with an operative blood loss of 450 mL. The patient was discharged home on postoperative day 5, which is slightly shorter than conventional surgery. The patient has been followed for 12 months and is doing well at home. A follow-up CT scan at 1-year postoperatively showed the hybrid graft in excellent position (Fig 3). This case report presented a clinical situation in which a hybrid vascular graft was used for the treatment of an AAA. The purpose of the new vascular hybrid graft is to facilitate the distal anastomosis in the treatment of patients with AAA. This device is a combination of a conventional vascular graft and an endoprosthesis. The hybrid technique combines open and endovascular techniques. The conventional, handsewn technique provides a secure proximal anastomosis and oversews the backbleeding from the lumbar or inferior mesenteric arteries, and the endovascular technique facilitates the distal anastomosis. Potential issues with the hybrid graft could include separation, disconnection, kinking, or occlusion of the iliac limb components. We believe that the connections would be less problematic because of the active fixation with sutures and reinforcement with PTFE, as opposed to relying on the radial force of the endograft. Until recently, aortic aneurysms have been treated with either conventional grafts or endografts. EVAR provides a less invasive technique because of smaller incisions, no aortic cross clamp, and reduced cardiac stress. However, two major weaknesses of EVAR can lead to the eventual failure of the stent graft. First, the proximal attachment of the stent graft relies solely on the radial force or small hooks of the stent graft. Over time, the aortic neck can dilate and the stent graft can migrate,14Cao P. Verzini F. Zannetti S. Parlani G. De Rango P. Parente B. et al.Predictive factors and clinical consequences of proximal aortic neck dilatation in 230 patients undergoing abdominal aorta aneurysm repair with self-expandable stent-grafts.J Vasc Surg. 2002; 37: 1200-1205Abstract Full Text Full Text PDF Scopus (128) Google Scholar increasing the likelihood of aneurysm rupture after EVAR.12Schlensak C. Doenst T. Hauer M. Moreno J.B. Uhrmeister P. Spillner G. Beyersdorf F. Serious complications requiring surgical interventions after endoluminal stent graft placement for the treatment of infrarenal aortic aneurysms.J Vasc Surg. 2001; 34: 198-203Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar The advantage of a handsewn, proximal anastomosis relies on the ability to secure the graft to the aortic wall; however, it can result in a para-anastomotic aneurysm over time. The second problem associated with stent grafts are type II endoleaks, which occur in 10% to 44% of all EVAR cases.6Veith F.J. Baum R.A. Ohki T. Amor M. Adiseshiah M. Blankensteijn J.D. et al.Nature and significance of endoleaks and endotension summary of opinions expressed at an international conference.J Vasc Surg. 2002; 35: 1029-1035Abstract Full Text Full Text PDF PubMed Scopus (509) Google Scholar Even after an initially successful exclusion of the AAA, the patent lumbar arteries or the IMA can increase the AAA diameter via its access to the sac of the aneurysm outside the endograft. The unpredictability of the natural history of an endoleak calls for the need of a life-long surveillance of the stent-graft device.6Veith F.J. Baum R.A. Ohki T. Amor M. Adiseshiah M. Blankensteijn J.D. et al.Nature and significance of endoleaks and endotension summary of opinions expressed at an international conference.J Vasc Surg. 2002; 35: 1029-1035Abstract Full Text Full Text PDF PubMed Scopus (509) Google Scholar The durability of the standard repair stems from securing the proximal anastomosis and oversewing the lumbar arteries or IMA. We believe that this hybrid vascular graft has the potential for use in open aneurysm repair and in laparoscopic or robotic-assisted aortic surgery. These less invasive techniques still suffer from longer cross-clamp times compared with open surgery. One future application is to suture the proximal part to the aortic wall with conventional, laparoscopic, or robotic-assisted techniques, as well as with an aortic stapling device. The distal part is performed by endovascular technique under fluoroscopic guidance. Any clamping of the common iliac artery is avoided using balloon occlusion, especially in severely calcified vessels. Although this case report presents a single clinical situation, the vascular hybrid graft potentially can be offered to patients fit for surgery who are undergoing a less invasive laparoscopic procedure with a reduced clamp time compared with a totally laparoscopic aortic operation.