• Hypertensive Disease
• Obesity
• Coronary Artery Disease
• Interventional Techniques & Devices

• Cardiology & Cardiovascular Medicine
• Hypertensive Disease
• Obesity
• Coronary Artery Disease
• Interventional Techniques & Devices

The majority of aortic abdominal aneurysms (AAAs) in the United States are repaired using an endovascular approach. Evolving techniques and technology have expanded the population eligible for an endovascular approach making it possible to use this approach in patients who were previously not considered good candidates according to Patricio Rosa, MD, Delray Medical Center, Delray Beach, Florida, USA. Dr. Rosa also noted that novel techniques and devices may further increase the number of endovascular procedures.

AAAs occur in ∼2% to 5% of men aged >60 years and result in 9000 deaths per year in the United States. Open surgical repair was been the treatment of choice for many years; however, this procedure is associated with a high morbidity and mortality in some patient populations. For example, some studies have shown that the 1-year mortality of high-risk patients aged >70 years with chronic obstructive pulmonary disorder who undergo a suprarenal cross clamp can be as high as ∼30% [Beck A et al. J Vasc Surg 2009]. Therefore, physicians have developed the chimney technique (stenting side branches), which is one technique that allows the physician to perform the procedure through an endovascular approach (Figure 1).

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Figure 1.

The Chimney Technique

Reproduced from Bruen KJ et al. Endovascular chimney technique versus open repair of juxtarenal and suprarenal aneurysms. J Vasc Surg 2011;53(4):895–905. With permission from Elsevier.

Early data suggests that the chimney technique may provide results that are similar to open procedures in terms of success of repair even when the patient has anatomy that makes traditional endovascular repair difficult, said Dr. Rosa. In a nonrandomized study of 21 patients with juxtarenal or pararenal aneurysms who underwent repair using the chimney technique and were compared with 21 matched open cases, mortality was similar at 4.8% in each group (one death in each group). The frequency of renal dysfunction was also similar between the two groups occurring in 6 patients (29%) in the endovascular group and 5 patients (1 patient with acute kidney injury and 4 patients with acute renal failure) in the open group. Dr. Rosa pointed out that this yielded a rate of renal complications similar to that found in the literature for open cases in which the renal cross-clamp is performed [Bruen KJ et al. J Vasc Surg 2011].

Another technique that makes percutaneous aneurysm repair possible is the preclose method. This technique prepares the arteriotomy for percutaneous repair prior to removal of the sheath. This method was successful in 94.3% of cases according to a study in which 559 Proglide devices were used to repair 279 femoral arteries [Lee WA et al. J Vasc Surg 2007]. There were only 16 failures, some of which were attributed to patient obesity and severe calcifications of the artery. Dr. Rosa commented that even in the presence of severely calcified vessels, the preclose method could still be performed if used in conjunction with an ultrasound device.

Custom-made fenestrated grafts used to accommodate visceral arteries is another way to increase the available proximal landing zone in difficult to treat patients. According to a retrospective observational study conducted at the Cleveland Clinic [Greenberg RK et al. J Vasc Surg 2009], 30 patients were treated with fenestrated devices over a 1-year period, with a 100% procedural success rate. Two-year follow-up data was available for 23 patients, and showed that 69.6% of the patients experienced a decrease in size of their aneurysm. There were no aneurysm-related deaths, ruptures, or conversions into open repair at 2-year follow-up.

Dr. Rosa concluded that percutaneous repair of aneurysms has now become the predominant method of performing the procedure and will likely become even more widespread with the invention of new techniques and devices which expand their indication.

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