Aortic Aneurysms (eBook)

Foreword 5
Preface 6
Contents 8
Contributors 11
Chapter 1 16
Genetics of Abdominal Aortic Aneurysms 16
Introduction 16
Clinical Management and the Genetics of AAA 19
Identification of AAA-Susceptibility Loci by Genome-Wide DNA Linkage Analyses 20
Genetic Association Studies: From Candidate Gene Studies to Genome-Wide Analyses 22
Microarray-Based Global Gene Expression Profiling: An Unbiased Approach to Identify Signaling Pathways Altered in AAA 29
Animal Models Provide Important Information About Pathogenesis of AAA 32
Conclusions: The Future of Aneurysm Genetics 34
References 35
Chapter 2 42
Inflammatory Pathogenesis and Pathophysiology of Abdominal Aortic Aneurysms 42
Introduction 42
The Genetic Basis of the Inflammatory Response in AAA 45
Evidence of Inflammation in the Circulation of AAA Patients 46
Conclusions 47
References 48
Chapter 3 50
Contemporary Imaging of Aortic Disease 50
Introduction 50
Computed Tomography 52
Magnetic Resonance Imaging 58
Catheter-Based Vascular Imaging 65
References 68
Chapter 4 71
Medical Management of Small Aortic Abdominal Aortic Aneurysms 71
Clinical Problem of AAA 71
Current Treatment Modalities 73
Measuring Aneurysm Progression 74
Factors Influencing Aneurysm Progression 75
Tobacco 75
Statins 76
beta -blockers 77
ACE Inhibitors and Angiotensin Receptor Blockers 77
Macrolides 78
Tetracyclines 78
Considerations for Evaluating Medical Therapies 79
References 80
Chapter 5 84
Surgical Treatment of Nonruptured Infrarenal Abdominal Aortic Aneurysms 84
Definition 84
Historical Perspectives 85
Prevalence and Incidence 85
Diagnosis and Risk of Rupture 86
Preoperative Risk Assessment 88
Procedural Considerations 89
Technical Considerations 90
Postoperative Complications 99
References 101
Chapter 6 107
Patient Selection Criteria for Endovascular Aortic Aneurysm Repair 107
Introduction 107
Standard Criteria for AAA Repair 108
Aneurysmal Growth Rate 109
Risk of AAA Rupture While Under Observation 110
Mortality Risk from Surgical Repair of AAA 111
Patient Life Expectancy 111
Patient Selection for EVAR 111
Preoperative Assessment 112
Preoperative Imaging Evaluation 112
CT Scan Protocol 113
Anatomical Criteria 114
Evaluation of the Proximal Attachment Site (Infrarenal Neck, Proximal Landing Zone) 114
Evaluation of the Distal Attachment Site (Iliac Landing Zones) 117
Evaluation of the Diameter and Morphology of the Ilio-Femoral (Conduit/Access) Arteries 118
Involvement of the Major Vessels in the Aneurysmal Sac 119
Compliance with Follow-up Protocols 120
Special Circumstances in Patient Selection for EVAR 120
Not-So-Ideal Neck/Proximal Attachment Site 120
Symptomatic and Ruptured AAA 121
Aneurysms That Involve and Extend Above the Renal Artery: Juxtarenal/Suprarenal AAAs and Thoraco-Abdominal Aneurysms 122
Fenestrated Endografts 122
Reinforced Fenestrated Endografts 123
Directional Branch Endografts 123
Conclusions 124
References 124
Chapter 7 132
Endovascular Repair of Abdominal Aortic Aneurysms 132
Introduction 132
Patient Selection for Endovascular Repair 133
Stent Graft Trials 134
Zenith Trial Overview 134
Excluder Trial Overview 135
AneuRx Trial Overview 135
Endologix Trial Overview 136
Registries 136
Randomized Trials of Open and Endovascular AAA Repair 137
EVAR Clinical Trial Overview 137
The DREAM Trial 138
The EVAR Trials 138
Durability 140
Repair of Small Aneurysms 140
Cost-Effectiveness of EVAR 141
Conclusions 141
References 141
Chapter 8 144
Complications and Secondary Procedures after Elective Endovascular Aortic Aneurysm Repair 144
Endoleak 144
Clinically Significant Endoleaks 146
Questionable Significant Endoleaks 146
Late Occurring Endoleaks 147
Migration 147
Limb Ischemia 148
Device Failure 149
Graft Infection 149
Post-EVAR Implantation Syndrome 150
Access-Related Complications 150
Arterial Dissection 151
Arterial Rupture 151
Embolus 153
Thrombosis 153
False Aneurysms 153
Lymphocele 154
Local Wound (Surgical Site) Infections 154
Uncommon Complications 154
Spinal Cord, Colonic, and Pelvic Ischemia 154
Graft Enteric Fistula 155
Conclusion 155
References 155
Chapter 9 159
Fenestrated Endovascular Stent-Grafts: Current Applications 159
Introduction 159
Principles and Technique 160
Evolution of the Technique 161
Current Applications of Fenestrated Endografts 163
Limitations of the Technique 166
Results 166
Conclusion 167
References 168
Chapter 10 169
Open Surgical Treatment of Pararenal Abdominal Aortic Aneurysms 169
Introduction 169
Clinical Presentation 170
Operative Technique 173
References 177
Chapter 11 179
Pelvic Ischemia During Endovascular Abdominal Aortic Aneurysm Repair 179
Introduction 179
Pelvic Collateral Circulation 180
Pelvic Ischemia After Aortic Reconstruction 181
Gluteal Blood Supply and Perioperative Monitoring 182
Effects of IIA Interruption During EVAR 183
Buttock Claudication 183
Bowel Ischemia After EVAR 184
IIA Occlusion During EVAR 184
Preservation of IIA Perfusion During EVAR 186
Recommendations for the Prevention of PI During EVAR 187
References 188
Chapter 12 193
Open Operative Therapy for Ruptured Abdominal Aortic Aneurysm 193
Clinical Presentation 193
Diagnostic Studies 194
Plain Films 194
Abdominal Ultrasound 195
Computed tomography 195
MRI/MRA 195
Resuscitation and Transfer 195
Risk Scoring 197
1. Hardman Index 198
2. Glasgow Aneurysm Score (GAS) 198
3. Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM) 198
4. Vancouver Scoring System (VSS) 198
6. Multiple Organ Dysfunction Score (MODS) 199
Operative Strategy 199
Proximal Control 200
Distal Control 201
Operation 201
Abdominal Closure After RAAA 202
Postoperative Management 202
Late Survival 202
Conclusion 203
References 203
Chapter 13 207
Endovascular Repair of Ruptured Abdominal Aortic Aneurysm 207
Endovascular Aneurysm Repair of Ruptured Abdominal Aortic Aneurysms 207
Preoperative Evaluation and Management 208
Anatomic Canadacy for EVAR 209
Technical Considerations 210
Complications 210
Published Outcomes 213
Conclusions 214
References 214
Chapter 14 217
Complications After Endovascular Ruptured Abdominal Aortic Aneurysm Repair 217
Early Complications 218
Mortality 218
Technical Failure 218
Endoleak 219
Acute Conversion to Open Repair 220
Visceral Ischemia/Bowel Infarction 221
Abdominal Compartment Syndrome 221
Postimplant Syndrome 221
Paresis/Paraplegia 221
Acute Renal Failure 222
Late Complications 222
Endoleaks 222
Delayed Conversion to Open Repair 223
Graft Thrombosis 223
Graft Infection 223
Conclusion 224
References 224
Chapter 15 227
Treatment of Mycotic Abdominal Aortic Aneurysms and Infected Aortic Grafts 227
Introduction 227
Mycotic Aneurysms 228
Pathogenesis 228
Clinical Presentation 228
Diagnosis and Imaging 229
Treatment 230
Outcomes 234
Infected Aortic Grafts 235
Pathogenesis 235
Clinical Presentation 235
Diagnosis and Imaging 236
Treatment 239
Outcomes 240
Summary 242
References 242
Chapter 16 246
Evaluation and Management of Aortoenteric Fistula 246
Definition 246
Pathophysiology 247
Clinical Presentation 248
Diagnostic Evaluation 248
Treatment 250
Outcomes 252
References 253
Chapter 17 255
Management of Abdominal Aortic Aneurysm in the Setting of Coexistent Renal and Splanchnic Disease 255
Introduction 256
Renal Artery Stenosis and Aneurysms 257
History 257
Prevalence 257
Intervention on Renovascular Disease 258
Management Options for Aortic Aneurysm with Associated RAS 259
Open Surgical Options for Management of Aortic Aneurysm and Associated RAS 259
Endovascular Options for Management of Aortic Aneurysm and Associated RAS 261
MAS and Aortic Aneurysms 263
Prevalence 263
Intervention on Mesenteric Artery Disease 265
Management Options for Aortic Aneurysm Repair with Associated MAS 266
Evaluation of Aortic Aneurysm and Associated MAS 266
Open Surgical Options for Management of Aortic Aneurysm and Associated MAS 267
Endovascular Options for Management of Aortic Aneurysm and Associated MAS 267
Combination Approaches for Management of Aortic Aneurysm and Associated MAS 268
Conclusion 268
References 268
Chapter 18 271
Management of Abdominal Aortic Aneurysms in Patients with Renal Ectopia and Renal Fusion 271
Background and Prevalence 271
Embryology 272
Classification 272
Diagnosis and Imaging 277
Therapy 278
Open Repair 278
Endovascular Repair 281
Complications and Results 282
References 283
Chapter 19 285
Abdominal Aortic Aneurysms in Transplant Patients 285
Introduction 285
Pathophysiology 286
Overview of Immunosuppressive Medications 286
Modulation of Inflammation 287
Posttransplant Hemodynamics 288
Prevalence and Screening of Aneurysmal Disease in Transplant Patients 288
Which Transplant Patients Should Be Screened for Aneurysm Disease? 289
Clinical Management 289
Managing Immunosuppression in the Perioperative Period 289
When to Repair Aneurysms in Transplant Patients? 290
Technical Considerations of Aneurysm Repair in Transplant Patients 291
Heart and Lung Recipients 291
Liver Recipients 291
Pancreas Recipients 292
Kidney Recipients 293
Summary 294
References 295
Chapter 20 297
Inferior Vena Cava: Embryology and Anomalies 297
Embryology 297
Venous Anomalies 300
Epidemiology of Venous Anomalies 300
Retroaortic and Circumaortic Left Renal Vein 301
Left-Sided Vena Cava 304
Duplicated Vena Cava 306
Vena Caval Interruption with Azygos Continuation 308
Marsupial Cava 309
Absence of the Infrarenal Cava 309
Multiple Venous Anomalies 312
General Principles in the Management of Vena Caval Anomalies 313
References 313
Chapter 21 316
Aortocaval Fistula 316
Presentation 316
Diagnosis 317
Treatment 317
Operative Repair 318
Endovascular Repair 319
References 320
Chapter 22 321
Acute Limb Ischemia After Abdominal Aortic Aneurysm Repair 321
Introduction 321
Open Surgery 322
Early/Postoperative Limb Ischemia 322
Late Limb Ischemia 323
Endovascular Aneurysm Repair 324
Endograft Limb Occlusion 324
Anatomic Considerations 324
D evice-Specific Considerations and Outcomes 326
Interventions for Endograft Limb Occlusion 328
Other Causes of Limb Ischemia Fowllowing EVAR 328
Conclusion 329
References 329
Chapter 23 331
Mesenteric Ischemia Following Abdominal Aortic Aneurysm Repair 331
Definition 331
Incidence 331
Mesenteric Arterial Anatomy 332
Etiology 332
Anatomic 332
Embolic and Mechanical 334
Physiologic 334
Diagnosis and Management 337
Diagnosis 337
Management 338
Recommendations 339
Preoperative Planning 339
Treatment of the IMA 339
Treatment of the Internal Iliac Arteries 339
Conclusion 340
References 340
Chapter 24 342
Operative Therapy for the Descending and Thoracoabdominal Aorta 342
Preoperative Evaluation for Patients with Thoracoabdominal Aortic Aneurysm 342
Operative Techniques for Repair of TAAA 344
Open Operative TAAA Repair 344
Hybrid TAAA Repair 345
Postoperative Management 346
Conclusion 346
References 346
Chapter 25 348
Endovascular Repair of Thoracic Aortic Aneurysms 348
Arterial Access 348
Aortic Tortuosity 349
Stent-Graft Sizing 352
Neurological Complications 353
The Aortic Arch 353
The Thoracoabdominal Aorta 354
Conclusion 355
References 355
Chapter 26 358
Evaluation and Treatment of Isolated Common Iliac Artery Aneurysms 358
Epidemiology 358
Natural History and Risk of Rupture 359
Diagnostic Evaluation 359
Repair of Iliac Artery Aneurysms 360
Surgical Repair 361
Endoluminal Repair 361
References 362
Chapter 27 363
Diagnosis, Evaluation, and Management of Isolated Hypogastric Artery Aneurysms 363
Diagnosis 363
Management 364
References 364
Chapter 28 366
True Femoral and Popliteal Artery Aneurysms: Clinical Features and Treatment 366
True Peripheral Artery Aneurysms 366
Demographics 367
Pathogenesis 367
Diagnosis 367
Presentation and Indications for Repair 369
Treatment: Popliteal Artery Aneurysms 371
Endovascular Treatment 371
Surgical Treatment 372
Treatment: Common Femoral Artery Aneurysms 373
Surgical 373
Thrombolysis for Acute Ischemia Related to AA 374
Nonoperative Treatment 375
Conclusion 375
References 375
Index 378