Faculty Bibliography

OBJECTIVE: An accepted fact is that abdominal aortic aneurysms (AAAs) larger than 5.5 cm should undergo elective repair. However, subsets of these patients have serious comorbid conditions, which greatly increase operative risk. This study evaluated the outcomes of periods of protracted nonoperative observational management with selective delayed surgery in patients at high risk with large infrarenal and pararenal AAAs. METHODS: Among 226 patients with AAAs more than 5.5 cm, we selected 72 with AAAs from 5.6 to 12.0 cm (mean, 7.0 cm) for periods of nonoperative management because of their prohibitive surgical risks. Comorbid factors included a low ejection fraction of 15% to 34% (mean, 22%) in 18 patients, 1 second forced expiratory volume less than 50% (mean, 38%) in 25, prior laparotomy in 10, and morbid obesity in 22. Follow-up examination was complete in the 72 patients for the 6 to 76 months (mean, 23 months) that they underwent nonoperative treatment. Fifty-three patients ultimately underwent operation because of AAA enlargement or onset of symptoms after 6 to 72 months (mean, 19 months) of nonoperative treatment. RESULTS: Of the 72 selected patients, 54 (75%) are living and 18 (25%) are dead. Seven patients who underwent only nonoperative treatment presently survive after 28 to 76 months (mean, 48 months). Of the 18 deaths, AAA rupture occurred in only three patients (4%) who were observed for 12, 31, and 72 months before rupture. Nine other deaths (13%) occurred after 6 to 72 months from comorbidities unrelated to the AAA. Six of the 53 patients who underwent delayed operation died within 30 days of operation (11% mortality rate). The mortality rate for the 154 good-risk patients with an AAA who underwent prompt open or endovascular repair was 2.2%. CONCLUSION: These data indicate that some patients with large AAAs and serious comorbidities are acceptably managed for long periods (6 to 76 months) with nonoperative means. Substantial delays of 12 to 76 months resulted in an AAA rupture rate of only 4%, and 13% of these patients (nine of 72) died of comorbidities unrelated to AAA rupture or surgery. Mortality rate in this group of patients, when operated, was 11% (six of 53). These findings support the selective use of nonoperative management in some patients with large AAAs and serious comorbidities

OBJECTIVE: To analyze the late complications after endovascular graft repair of elective abdominal aortic aneurysms (AAAs) at the authors' institution since November 1992. SUMMARY BACKGROUND DATA: Recently, the use of endovascular grafts for the treatment of AAAs has increased dramatically. However, there is little midterm or long-term proof of their efficacy. METHODS: During the past 9 years, 239 endovascular graft repairs were performed for nonruptured AAAs, many (86%) in high-risk patients or in those with complex anatomy. The grafts used were Montefiore (n = 97), Ancure/EVT (n = 14), Vanguard (n = 16), Talent (n = 47), Excluder (n = 20), AneuRx (n = 29), and Zenith (n = 16). All but the AneuRx and Ancure repairs were performed as part of a U.S. phase 1 or phase 2 clinical trial under a Food and Drug Administration investigational device exemption. Procedural outcomes and follow-up results were prospectively recorded. RESULTS: The major complication and death rates within 30 days of endovascular graft repair were 17.6% and 8.5%, respectively. The technical success rate with complete AAA exclusion was 88.7%. During follow-up to 75 months (mean +/- standard deviation, 15.7 +/- 6.3 months), 53 patients (22%) died of unrelated causes. Two AAAs treated with endovascular grafts ruptured and were surgically repaired, with one death. Other late complications included type 1 endoleak (n = 7), aortoduodenal fistula (n = 2), graft thrombosis/stenosis (n = 7), limb separation or fabric tear with a subsequent type 3 endoleak (n = 1), and a persistent type 2 endoleak (n = 13). Secondary intervention or surgery was required in 23 patients (10%). These included deployment of a second graft (n = 4), open AAA repair (n = 5), coil embolization (n = 6), extraanatomic bypass (n = 4), and stent placement (n = 3). CONCLUSION: With longer follow-up, complications occurred with increasing frequency. Although most could be managed with some form of endovascular reintervention, some complications resulted in a high death rate. Although endovascular graft repair is less invasive and sometimes effective in the long term, it is often not a definitive procedure. These findings mandate long-term surveillance and prospective studies to prove the effectiveness of endovascular graft repair