Riambau Alonso Vicente

If the aneurysm is small, with unlikely probability of rupture or complications and is located within the abdominal aorta, its progression can be followed by regular sonography. If it is of a larger size, expanding or its location is precarious, treatment consists of substituting the aneurysmal portion of the artery with an artificial artery of synthetic material. For this purpose, the conventional surgical technique employs large incisions to reach the area of the aorta, clamp it and replace the aneurysm with a synthetic vascular graft by sewing it to the healthiest vascular extremes. This technique which we have been performing for dozens of years, is being progressively replaced by endovascular techniques which offer similar results by means of less aggressive procedures.

The new endovascular techniques, permit, when the anatomy is favorable, to treat the aneurysm by means of placing an expandable graft, inside the vessel, without the necessity of open surgical procedures (by means of the vessels of the extremities, commonly the femoral arteries). The graft is introduced by means of catheterization and is spread out in a determined position guided by fluoroscopy of high definition. Blood circulates inside the graft and, likewise, is protected from growth and rupture of the aorta, leading to a reduction in size with time.

Scheme of implantation of a graft of the abdominal aorta

• Mini-incisions
• Introducer
• Guide
• Introduction of the guide by the femoral artery
• Introduction of the carrier system
• Unfolding of the graft
• Characterization of the contralateral branch
• Spreading out of the contralateral branch and digit

From the first clinical experience in the endovascular repair of abdominal aortic aneurysms in 1990, more than 300,000 synthetic grafts have been placed in abdominal aortic aneurysms and more than 30,000 commercially made grafts in thoracic aneurysms (some 5,000 and 1,000, respectively, in Spain).

If we focus on the pathology of the aorta, concretely aortic and thoracic aneurysms, 5 - 10% of male patients older than 65, suffer from these, which pose an implicit threat to their lives. We understand that any solution or improvement in their diagnosis, and especially in their treatment, involves all the professionals that deal direct- or indirectly with this pathology and evidently for the patients that suffer from it. It is in the repair of the aortic and thoracic aneurysms in which this technique has its greatest and most prominent application.

Pathologies such as the acute aortic syndrome (acute type B dissection, penetrating ulcers, intramural hematomas) traumatic injuries, pseudoaneurysms, chronic type B dissections, and aortobronchial and aorto-esophageal fistulas are potentially treated by means of an endovascular technique. Because of this, endovascular treatment of thoracic aneurysms merits special consideration both for patients, as well as for health care professionals.

Other grave vascular pathologies such as severe ischemia of the lower extremities or obstructions of the cervical or carotid arteries are potential indications for endovascular techniques.

Before Endovascular Treatment,at one year and at two years, when the aneurysm has disappeared.

In the Eurostar series, with more than 10,000 cases included, the immediate mortality recorded within the first 30 days after surgery is less than 2%, 5% of which are directly related to the procedure. The remaining registered deaths correspond to myocardial infarctions, respiratory failure, multi-organ system failure or sepsis. The mortality is greater in those patients considered not candidates for conventional or general anesthesia. Both the general conditions of the patient as well as the necessity of applying adjuvant therapies during the procedure are related significantly to the greater numbers of immediate mortality. The cumulative survival at five years of follow-up is around 77.2%. In our group, the perioperative mortality is around 1% and the survival rate at five years is 82%.

Conventional surgery offers a perioperative rate around 4% and a rate of complications around 20%. International multi-centric prospective studies that compare open surgery with endovascular, coincide, emphasizing that endovascular treatment results in a drastic reduction of mortality and complications related to surgery, length of hospital stay in the ICU and medical units, the need for transfusion and recovery time of the patients.

Principal complications: endoleaks (any presence of circulating blood in the aneurysmal sac, between the graft and the wall of the aorta), constitute the principal complication. The rate of leaks in our group is 6%, the majority of them without clinical repercussions and with favorable outcomes.

Of the data corresponding to the afore-mentioned studies, it follows as a logical corollary that the lesions in the access point are calculated to be 4%. Approximately 1% of the cases are not complicated because of difficulty with their access. The association with adjuvant processes and the lack of experience of the therapeutic team constitute clear risk factors for vascular complications and the necessity of aborting the procedure. Conversion to emergency open surgery are in 1% of the cases, augmenting the mortality of the procedure up until 15%.

In our experience of about 20 years, with more than 1,300 endovascular cases of the aorta performed, the rate of conversion to open surgeries is 0%, the overall rate of complications does not reach 3% and the rate of mortality is less than 1%.

Throughout the procedure, other possible complications may occur, the worst and most likely are secondary endoleaks, migrations, infolding and the rupture of the potentially treated AAA. All of these can lead to the need to perform an endovascular re-intervention or open surgery. In our experience, we have not needed to convert any patient to open surgery, with the rate of re-intervention less than 6%. In our series, the average hospital stay has been less than two days.

In general, and as an example, an endovascular repair of the third portion of the descending thoracic aorta can be performed under local anesthesia, with a surgical time of less than one hour, without consumption of blood products nor special facilities, with a hospital stay of less than two days and an almost immediate physical recovery of the patient. Nevertheless, the uncertainty of the durability of this method is an argument which some critics of the technique put forth. For the majority, the technology on which endovascular treatment is based is solid and with time’s demonstrating its enormous utility, owing to the favorable experience of the cases treated.

Just as it occurs for the abdominal endografts, patients must meet the anatomical and morphological requisites in order for the endograft to be securely anchored, without occluding indispensable branches of the thoracic aorta (or coronary, supra-aortic, visceral or spinal arterial trunks, as well as access from the femoral arteries.