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February, 1998
The two papers this month were both published in the
January issue of JVS. This issue is also noteworthy
for the splendid address of Robert Smith III to the
June 1997 meeting of the North American Chapter of the
International Society for Cardiovascular Surgery,
entitled, "Presidential address: The foundations of
modern aortic surgery." The serious action begins in
1950 when Jaques Oudot of Paris (whose contributions
are much less widely appreciated today than those of
Charles Dubost) performed the first resection and
homograft replacement of a thrombosed aortic
bifurcation. Much of the rest of the paper is devoted
to the monumental achievements of Arthur Voorhees of
Columbia P&S, who was one of Bob Smith's most
influential teachers. The paper makes such fine
reading in the original that I will not make further
attempts to summarize it, but I recommend it to all
students of vascular surgery.
1. Wain RA, Marin ML, Ohki T, et al. Endoleaks after
endovascular graft treatment of aortic aneurysms:
Classification, risk factors, and outcome. JVS
1998;27:69-80.
Summary by MDT: This report describes the treatment of
47 AAA's by a variety of endovascular methods over a
recent 5 year period, with a total of 17 endoleaks, as
summarized below:
# # %
Uncorrected chi sq
Phase I c leak c leak vs
Phase II
EVT tube 4 3 75%
.03
AortoAortic Tube 7 4 57%
.06
AortoIliac c femfem 8 4 50%
.11
Phase II
Aortofem c femfem 28 6 21%
Comment by MDT: A very impressive documentation of
progress from the Phase I leak rates equal to or
greater than 50% to the Phase II leak rate of 21%.
Quoting the authors: "In phase II, all of the patients
were treated with tapered aortofemoral endovascular
grafts and femorofemorol bypass grafts with occlusion
of the opposite iliac artery. The proximal stent of
these grafts was deployed near or across the orifice of
one or both renal arteries.. The graft ended distally
in the common femoral artery with a sutured endoluminal
anastomosis."
So, the interesting question, as raised in the
discussion by David Brewster (MGH/Harvard) is whether
the improvement lies in refinement of the configuration
of the graft or simply increasing experience on the
part of the team. Dr. Wain felt that both factors
played a role (and so does mdt). The fact that one
patient with a persistent endoleak ruptured his AAA and
died underscores a recurring theme in these Papers of
the Month - that this procedure continues to be
experimental.
2. Kline RG, D'Angelo AJ, Chen MHM, Halpern VJ, Cohen
JR. Laparoscopically assisted AAA repair: First 20
cases. JVS 1998; 27: 81-8.
Abstract (shortened from authors):
Purpose: Laparoscopic surgery decreases post-operative
pain, shortens hospital stay, and returns patients to
full functional status more quickly than open surgery
for a variety of surgical procedures. This study was
undertaken to evaluate laparoscopic techniques for
application to AAA repair.
Methods & Results: Twenty patients undergoing
laparoscopically assisted tube graft replacement are
the subject of this report. The procedure was
completed in 18/20 patients, with a mean total
operative time of 4.1 hours. There were two minor
complications, one major complication (colon ischemia &
colectomy), and no deaths. Mean NG suction was 1 day;
mean ICU stay was 2 days; and mean hospital stay was 6
days (excluding 3 patients who underwent other
procedures).
Conclusion: Lap assisted AAA repair is technically
challenging but feasible... Further refinement in
technique and instrumentation will make total lap AAA
repair a reality.
Comment by mdt: It speaks for itself that these initial
results are encouraging; and, as Jon Cohen said in his
response to a question from Jeb Hallett, "It is amazing
to see them on the first postop day sitting up ready to
eat and ready to go home by the third or fourth day."
And, I might add, one may hope that this approach will
not be subject to some of the late problems like
endoleaks that occur after endovascular repair. I
congratulate Dr. Cohen and his group on their progress
to date.