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Natural History and Open Treatment of Isolated Iliac Artery Aneurysms

The Ad Hoc Committee on Reporting Standards of the Society for Vascular Surgery and the International Committee on Reporting Standards of Cardiovascular Surgery, North American Chapter, define iliac artery aneurysms (IAAs) as any permanent localized dilation of the iliac artery larger than 1.5 cm in diameter. Normal ranges are reported to be from 0.95 to 1.10 cm in women and 1.04 to 1.30 in men, gradually…

Open Surgical Treatment of Aortic Dissection

Acknowledgments The authors thank Scott A. Weldon, MA, CMI, and Carol P. Larson, BS, AMI, for their outstanding medical illustrations and Stephen N. Palmer, PhD, ELS, and Susan Y. Green, MPH, for invaluable editorial support. Improvements in anesthesia, surgical techniques, and perioperative care have improved the odds of survival for patients with acute aortic dissection. Additionally, collaborations such as the International Registry of Acute Aortic Dissection…

Endovascular Treatment of Aortic Dissection

Acute aortic dissection causes death by rupture of the false lumen or by end-organ malperfusion. Untreated acute type A dissection has a mortality of approximately 50% within 48 hours, predominantly caused by rupture resulting in cardiac tamponade. Acute type B dissections have a mortality of approximately 25%, which doubles when the dissection is complicated by paraplegia or by renal, mesenteric, or lower extremity ischemia. In recent…

Nonoperative Medical Management of Acute Aortic Dissection

Acute aortic dissection should be considered a constituent of acute aortic syndrome (AAS) together with intramural hematoma (IMH), penetrating atherosclerotic ulcer (PAU), and aortic rupture. The common denominator of AAS is disruption of the media layer of the aorta, with bleeding within the media layers or separation of the layers of the aorta (dissection). In 90% of cases, an intimal disruption is present that results in…

Paraplegia Prevention in Thoracic and Thoracoabdominal Aortic Aneurysm Repair

The overlapping effects of aortic occlusion, collateral blood flow, metabolism, oxygen supply and demand, surgical technique, and response to ischemia underlie the unpredictability of spinal cord ischemia and subsequent paralysis in the surgical treatment of thoracoabdominal aortic aneurysms (TAAAs). However, experimentally validated interventions that enhance collateral circulation, increase ischemic tolerance, and add neurochemical protection have reduced the paraplegia risk by 80% to 90% since the 1980s…

Open Surgical Treatment of Thoracoabdominal Aortic Aneurysms

Aneurysms involving the thoracoabdominal aorta are uncommon, but they receive significant attention due to their complexity of repair and risk of end-organ impairment. Advances in preoperative planning, surgical technique, anesthesia, and postoperative management have led to improved outcomes, most notably with regard to postoperative neurologic deficit. Open repair of such aneurysms remains a formidable operation for both surgeon and patient. The pace of endovascular repair of…

Open Surgical Treatment of Thoracic Aortic Aneurysms

Descending thoracic aortic aneurysms (TAAs) are categorized into three types. In type A the descending TAA starts at the level of the left subclavian artery and ends at the level of T6. Type B starts at T6 and ends at the level of the diaphragm. Type C involves the total descending thoracic aorta. It is not uncommon for descending TAAs to involve the distal aortic arch.…

Multibranched Endovascular Repair of Thoracoabdominal Aortic Aneurysm

Endovascular aneurysm repair, which requires neither direct aortic exposure nor temporary interruption of aortic flow, is particularly appealing when treating thoracoabdominal aortic aneurysms (TAAAs). Yet more than a decade has passed since a multibranched stent graft was first used to treat a TAAA, and the endovascular approach has yet to displace open surgery from its role as the mainstay of TAAA treatment, mainly because there is…

Endograft (VORTEC) Reconstruction of Aortic Branches Allowing Endovascular Treatment of Aortic Aneurysms

Viabahn open revascularization technique (VORTEC) is a stent graft–based vascular connection technique that achieves 97% successful end-to-end sutureless anastomoses, which is useful especially when the traditional suture technique is cumbersome. Open graft repair of the aortic arch and thoracoabdominal aorta, with the exception of a few very experienced high-volume centers, generally carries a high mortality as well as a severe long-lasting morbidity. To overcome these limitations,…

Thoracic and Abdominal Aortic Debranching in the Endovascular Treatment of Thoracoabdominal Aortic Aneurysms

It is not always feasible to obtain adequate sealing regions for endovascular grafts without compromising renal artery and visceral arterial blood flow when treating juxtarenal abdominal aortic aneurysms (AAAs) and thoracoabdominal aortic aneurysms (TAAAs). Similar anatomic constraints exist with respect to the great vessels during the repair of arch or proximal descending thoracic aortic aneurysms (TAAs). Covering any of these major branches can result in devastating…

Endovascular Treatment of Thoracic Aortic Aneurysms

The first description of a remote placement of a stent graft was by Volodos in 1986, although it was undertaken in treating a stenosis and dissection. Because it was published in Russian, there was little notice in the English-speaking countries. After the 1991 publications by Volodos and Parodi of the treatment of abdominal aortic aneurysms, the technique of endovascular aneurysm repair (EVAR) gained popularity. The first…

Recognition and Treatment of Abdominal Compartment Syndrome Following Ruptured Abdominal Aortic Aneurysm Repair

Abdominal compartment syndrome (ACS) and intraabdominal hypertension (IAH) caused by elevated intraabdominal pressure (IAP) are commonly encountered in patients with ruptured abdominal aortic aneurysms (AAAs) and carry a high morbidity and mortality risk ( Table 1 ). However, IAH/ACS are still overlooked by many physicians and therefore timely diagnosis is not made and treatment is often inadequate. TABLE 1 Incidence and Mortality of Abdominal Compartment Syndrome…

Open Abdominal Aortic Aneurysm Repair and Concurrent Nonvascular Disease

Concomitant intraabdominal procedures with abdominal aortic aneurysm (AAA) repair are seldom necessary. The most life-threatening issue for the patient with concurrent nonvascular disease and an AAA is dealt with first, followed by the secondary procedure when it is medically safe. Endovascular aneurysm repair (EVAR) has simplified dealing with concurrent nonvascular disease. Synchronous Disease A variety of nonvascular disease states can coexist with an abdominal aortic aneurysm,…

Open and Endovascular Repair of Abdominal Aortic Aneurysms in Kidney Transplant Patients

Aortic reconstructions for an abdominal aortic aneurysm (AAA) in kidney transplant recipients have been increasing steadily since the 1990s for a variety of reasons: These patients often have accelerated atherosclerosis caused by hemodialysis and other cardiovascular risk factors; renal transplantation has been extended to older and more high-risk patients in whom an AAA is more likely; and AAAs tend to grow faster in patients who receive…

Renal Ectopia and Renal Fusion in Patients Requiring Abdominal Aortic Operations

Renal ectopia is a developmental anomaly in which the position of one or both kidneys is abnormal. It can occur alone or in combination with fusion or malrotation of both renal masses. Congenital anomalies of the upper urinary tract are among the most common organ system anomalies encountered by the vascular surgeon, and they may also commonly be associated with coexisting anomalies of renal vasculature and…

Management of Primary Aortoenteric Fistulas

Fistulas between major vascular structures and the intestinal tract are grouped into two categories: primary and secondary. A primary aortoenteric fistula is an abnormal spontaneous communication between the aorta and a segment of the alimentary tract without any history of previous aortic operation. A secondary aortoenteric fistula is caused by the erosion of a component of a previous vascular reconstruction, usually a prosthetic graft into a…

Autotransfusion in Aortic Reconstruction

Significant positive advances have been made over the past half century in both the safety and efficacy of open aortic reconstruction for the treatment of either aneurysmal or occlusive diseases of the aorta. These operations are associated at times with estimated blood loss sufficient to require blood replacement therapy to restore blood volume and homeostasis. Autotransfusion of blood or blood components is one method to successfully…