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It seems pretty well settled now that endovascular repair of AAA can
accomplished with less up front mortality risk than conventional surgical
repair. This month I will briefly take note of two articles that would in
general favor migration to endovascular repair when technically
possible. The first is a paper about erectile dysfunction (ED) after
conventional repair, and ED appears to be much more common than
most of us (including mself) have thought. The second is a landmark
paper from U Cal San Francisco, first authored by a pioneer in the
field (Tim Chuter), on very encouraging results of endovascular repair
in a group of patients who would be very high risk for conventional
repair.
However, the next two papers are cautionary tales of late failure of
endografts. As more and more devices have been implanted for
longer periods of time, will late failure become more of a problem??
I don't know.
The final (fifth) paper is an interesting contribution to defining the
natural history of the AAA sac after endografting.
1. Lee ES, Kor DJ, Kuskowski MA, Santilli SM. Incidence of
erectile dysfunction after open AAA repair. Ann Vasc SUrg 2000;
14: 13-19.
Brief summary: Questionaires were mailed to 175 males who had
undergone an open AAA repair. Sixty-eight responded, and 67
of them reported worsening ED; one reported improvement.
2. Chuter TAM et al. Endovascular aneurysm repair in high-risk
patients. J Vasc Surg 2000; 31: 122-33.
Brief summary: Endovasc repair was performed in 116 patients who
had ASA grades of II (3%), III (66%), IV (30%) and V (1%). 30
day mortality was 3.4% in the first 58 patients, and 0% in the last
58. Please see paper for much more detail.
3. Politz JK, Newman VS, Stewart MT. Late AAA rupture after
AneuRx repair: a report of 3 cases. J Vasc Surg 2000; 31: 599-606.
4. Zarins CK, White RA, Fogarty TJ. Aneurysm rupture after
endovascular repair using the AneuRx stent graft. J Vasc Surg
2000; 31: 960-70.
Brief summary: Late rupture between 3 weeks and 24 months post-
op occurred in seven (0.7%) of 1046 successfully implanted
endografts. Please see paper for a great deal of important detail,
including life-table analysis.
Comment by mdt: Zarins continues to be a leader in the field of
endovascular technology, and the whole working group deserves
compliments for achieving a probability of no rupture of 99.6 %
at one year and 97.4% at two years. Hopefully, the problem will
not increase as more devices age.
5. Singh-Ranger R et al. The AAA sac after endoluminal exclusion:
a medium-term morphologic follow-up based on volumetric
technology. J Vasc Surg 2000; 31-490-500.
Comment by mdt: This paper has a wealth of information that
will be of interest to endovascular surgeons and radiologists;
but what caught my attention was the curious finding that
pre-expanded PTFE grafts fixed with Palmaz stents showed
an *increase* in sac volume from 129 mL to 141 mL at 5 days,
and the increase was persistent at 18 month followup. With
the endografts, there was an initial increase, but after 6 mos
and 1 year there was significant shrinkage. In light of papers
#'s 3 and 4 this month, it is obviously going to be interesting
scientifically to find out what the molecular messages may
be that *shrink* AAA sacs.