The Aneurysm Information Project

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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.