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Papers of the Month - August 1998
1. Two cautionary tales regarding late complications of
endovascular repairs appeared in the July issue of the
Journal of Vascular Surgery:
1) Torsello et al. Rupture of AAA previously
treated by endovascular stentgraft. JVS 1998; 28: 184-7.
In brief, the patient was a 76 y/o on Coumadin after
aortic valve replacement, who ruptured 16 months post-
endograft. Seven months after stentgraft repair, there
had been no evidence of endoleak.
2) Alimi et al. Rupture of an AAA after
endovascular graft placement and aneurysm size reduction.
J Vasc Surg 1998; 28: 178-83.
This patient ruptured "9 months after a bifurcated
endovascular graft placement, despite a greater than 45%
reduction in size noted on contrast-enhanced computed
tomography scan performed at 7 months." The authors
believe that a "secondary detachment of the left limb
tube from the short limb of the main part of the device"
may have resulted from "degradations both the
textile structure and the stent shape."
Comment by mdt: These reports dramatize the dilemma
faced by physicians and surgeons who are called on to
advise patients about which approach is the best choice
for themselves. The trade off for perhaps a lower
initial risk and more rapid recovery from the
endovascular method is a less durable operation for the
long run, at least at the present state of the art.
2. Scott RAP et al. AAA rupture rates: A 7-year follow-
up of the entire AAA population detected by screening.
J Vasc Surg 1998; 28: 124-8.
Abstract (Abridged from authors): 218 AAA's were
detected by ultrasound among a family practice population
of 5394 men and women aged 65-80. Subjects with AAA < 6
cm were followed by ultrasound according to protocol.
Patients were offered surgery if 1) symptomatic; 2) if
AAA expanded > 1 cm/yr; or 3) If AAA diam reached 6 cm.
Results & Conclusions: The actual rupture rate plus
elective surgery rate for small AAA's (3-4.4 cm) was 2.1%
per year. The equivalent rate for 4.5-5.9 cm AAA's was
10.2% per year.
Comment by mdt: Since the authors chose to stratify
at 4.4 vs 4.5 to compare smaller vs larger AAA's, the
results cannot be directly compared with the Univ Vermont
data, which grouped AAA's into < 4cm, 4.0-4.9 cm, >5 cm
subsets. However, there is a high level of agreement
that rupture risk increases substantially toward the
higher ends of the ranges under study.