Background The treatment of aortic aneurysms with endovascularstents or stent–graft prostheses is receiving increasingattention as an alternative to major abdominal surgery. To definethe clinical value of this technique, we prospectively studiedthe use of stent–graft endoprostheses made of nitinoland covered with polyester fabric for the treatment of infrarenalabdominal aortic aneurysms.
Methods We treated a total of 154 patients at three academichospitals. Twenty-one patients with aortic aneurysms not involvingthe aortic bifurcation received straight stent–grafts,and 133 patients with aortic aneurysms involving the bifurcationand the common iliac arteries received bifurcated stent–grafts.After a unilateral surgical arteriotomy, the endoprostheseswere advanced through the femoral arteries and placed underfluoroscopic guidance. Computed tomography and intraarterialangiography were performed during an average follow-up of 12.5months.
Results The primary success rate, defined as complete exclusionof the abdominal aortic aneurysm from the circulation, was 86percent in the group receiving straight grafts and 87 percentin the group receiving bifurcated grafts. In three patientsthe procedure had to be converted to an open surgical operation.Minor (n = 13) or major (n = 3) complications associated withthe procedure (including 1 death) occurred in 10 percent ofthe patients. All patients had a postimplantation syndrome,with leukocytosis and elevated C-reactive protein levels.
Conclusions Our results suggest that endovascular treatmentof infrarenal abdominal aortic aneurysms is technically feasibleand can effectively exclude abdominal aortic aneurysms fromthe circulation. With further refinement, endoluminal repairmay emerge as an interventional strategy to treat infrarenalaortic aneurysms, especially in patients at high surgical risk.
The routine management of aortic aneurysms is surgical, withplacement of a graft in the involved segment.1,2 Surgical treatmentof nonruptured abdominal aortic aneurysms is associated withan overall mortality rate of 1.4 to 7.6 percent,3,4,5 and therate is as high as 10 percent in patients with symptomatic aneurysms.6With the percutaneous placement of endoluminal stent–grafts,major abdominal surgery and the related morbidity and mortalitycan be avoided. This is particularly important because of thehigh incidence of coexisting morbid conditions7,8 in unselectedpatients between 65 and 80 years of age, in whom the prevalenceof abdominal aortic aneurysm is rather high (3 percent).9,10
The use of endoprostheses was first proposed by Dotter in 1969.11In 1986 Balko et al. reported the repair of artificially inducedaneurysms with polyurethane prostheses in animals.12 This wasfollowed by several reports of experimental endoluminal graftingin animal models.13,14,15,16,17,18,19,20,21,22 The use of straightgrafts in patients with aortic dissection or abdominal aorticaneurysms was first described in 1991 by Parodi et al.23 Sincethen, endoluminal treatment of aneurysms of the thoracic andinfrarenal abdominal aorta with different types of endoprostheseshas been used in a number of centers.24,25,26,27,28,29,30,31,32,33,34,35,36
We report the short-term and midterm results of stent–graftingfor infrarenal abdominal aortic aneurysms with polyester-coverednitinol endoprostheses in 154 patients who would have otherwiserequired surgical repair. The aim of this study was to assessthe feasibility, rate of complications, and clinical effectivenessof endoluminal treatment of infrarenal abdominal aortic aneurysms.
Methods
Selection of Patients
Among 331 patients with infrarenal abdominal aortic aneurysmswho were referred to the three study hospitals between August1994 and April 1996 for evaluation, a total of 154 patients(47 percent) were treated by transfemoral placement of straightor bifurcated stent–grafts for aneurysms with maximaldiameters of 3.7 to 9.7 cm (mean, 5.4). Seventy-four patientswere treated at University Hospital, Freiburg, Germany; 47 atHenriettenstiftung, Hannover, Germany; and 33 at UniversityHospital, Vienna, Austria. The base-line clinical characteristicsof the patients and the types of abdominal aneurysms presentare listed in Table 1.
Table 1. Clinical Characteristics of 154 Patients with Abdominal Aortic Aneurysms Who Were Treated with Endoluminal Stent–Grafts.
The patients were selected on the basis of the anatomy of theaneurysm and the classification of the infrarenal abdominalaortic aneurysm. Patients selected for endoluminal therapy wereeligible for the study irrespective of their eligibility forsurgery.
To be included in the study the patients had to have an aneurysmclassified as type A, B, or C. A type A aneurysm had proximaland distal aortic necks that were more than 10 mm in lengthand less than 25 mm in diameter without involvement of the iliacarteries. A type B aneurysm involved the aortic bifurcationand had a proximal aortic neck that was more than 10 mm in lengthand less than 25 mm in diameter, with a common iliac arterythat was less than 12 mm in diameter. A type C aneurysm hada proximal aortic neck that was more than 10 mm in length andless than 25 mm in diameter and involved the common iliac arteriesand the iliac bifurcation (diameter, <12 mm).
Patients were excluded from the study if they had type D aneurysms(involvement of both internal iliac arteries), type E aneurysms(proximal aortic neck of <10 mm in length or >25 mm indiameter), or stenosis or occlusion of the superior mesentericartery, or if they were not available for follow-up.
The patients were divided into two groups according to the typeof the abdominal aortic aneurysm. In one group, only the abdominalaorta was involved (type A aneurysm), requiring the implantationof a straight stent–graft. In the second group, the aorticbifurcation or the bifurcation and the common iliac arterieswere involved (type B or C aneurysm), requiring the implantationof a bifurcated stent–graft.
All patients were informed about the procedure in detail andgave their written consent. The study protocol was approvedby the ethics committees of the three centers.
Endoprostheses
The stent–graft (Mialhe Stentor, MinTec, Freeport, Bahamas,and Vanguard, Boston Scientific, Oakland, N.J.) is a self-expandingendoprosthesis composed of a nitinol frame annealed into a tubularzigzag configuration by a 7-0 polypropylene thread37 and coveredwith a 0.1-mm woven-polyester fabric. The stent–graftsare straight (Figure 1A) or bifurcated (Figure 1B), dependingon the anatomy of the aneurysm.34 The bifurcated device hastwo components that are introduced separately and then joinedintraluminally: the larger component consists of an aortic andiliac graft with a short branch 10 mm in diameter into whichthe smaller component, which is placed in the contralateraliliac artery, is inserted. The devices are commercially availablein standard sizes (total length, 153 or 165 mm; diameter ofthe aortic section, 22, 24, or 26 mm; diameter of the iliacsection, 10 or 12 mm), or they can be custom-made.
Figure 1. Stent–Grafts Used for the Endoluminal Treatment of Infrarenal Abdominal Aortic Aneurysms.
The grafts are composed of a nitinol frame covered with a thin woven-polyester fabric. Panel A shows the straight stent–graft in which the top of the graft is not covered by fabric and has a row of barbs for anchoring into the proximal neck of the aneurysm. Panel B shows the bifurcated graft. The graft has two components that are inserted separately and then joined: the primary component consists of an aortic and iliac stent–graft with an attachment site for the secondary component, which is placed in the contralateral iliac artery.
Preprocedural Evaluation and Implantation Technique
To determine the length and diameter of the aneurysms, we performedmultiplane angiography using a graduated catheter and spiralcomputed tomography with three-dimensional vascular reconstructionsat least one week before the procedure in all patients consideredfor stent–graft implantation.34
The implantations were performed with the patients under generalanesthesia (n = 151) or local anesthesia (n = 3) in the angiographysuite (in the German hospitals) or in the operating room (inthe Austrian hospital) by teams of interventional radiologistsand vascular surgeons. The vascular surgeon performed the arteriotomy,and the radiologist placed the stent–graft. The patientswere prepared for surgery in case serious complications occurredor the endoluminal technique failed. The technique of placingthe stent–graft — illustrated in Figure 2 —and the peri-interventional and postinterventional managementhave been described previously.34
Figure 2. Placement of the Bifurcated Stent–Graft.
In Panel A, the aortic section with the attached iliac limb is implanted with use of a delivery system inserted through a surgical cutdown below the renal arteries. In Panel B, the contralateral iliac limb is inserted percutaneously.
Follow-Up Protocol
The follow-up protocol included intraarterial angiography andspiral computed tomography. The first follow-up study was performedin all patients before discharge, within seven days after theinitial procedure. Thereafter, all follow-up examinations wereperformed on an outpatient basis: the second examination wasconducted 3 months after the procedure (computed tomography),the third examination 6 months later (intraarterial angiographyand computed tomography), and the fourth and fifth examinationsafter 12 and 24 months, respectively (computed tomography).
Statistical Analysis
Continuous variables are expressed as means ±SD. Thelaboratory measurements made before and after stent–graftimplantation were compared by Student's t-test. A P value below0.05 was considered to indicate statistical significance.
Results
Primary Technical Results
Primary technical success, defined as the complete exclusionof the abdominal aortic aneurysm from the circulation, withrestoration of normal blood flow, was achieved in 134 of the154 patients (87 percent).
Type A Aneurysms
Transfemoral treatment with straight grafts was technicallysuccessful in 18 of 21 patients with type A abdominal aorticaneurysms (86 percent). Immediately after the procedure, angiographyrevealed proximal leaks in two patients due to short proximalnecks, which led to dislodgment of the stents, and a distalleak in one patient due to a short distal neck (<10 mm) (Table 2).
Table 2. Causes of Primary or Secondary Failure of Endoluminal Treatment of Abdominal Aortic Aneurysm.
The average length of time needed to implant the stent–graftwas 43±21 minutes in the first 6 patients and 30±5minutes in the last 15 patients. The total length of the procedure(including arteriotomy and closure) was 88±24 minutes(range, 50 to 220). The average hospital stay was 6.75±2.5days.
Type B and C Aneurysms
Endovascular repair with a bifurcated stent–graft wastechnically successful in 116 of 133 patients with type B orC aneurysms (87 percent) (Figure 3A and Figure 3B). In threepatients the procedure had to be converted to surgical repair.In one patient a coiled external iliac artery ruptured duringthe insertion of the delivery system, requiring emergency surgery.In the two other patients the 18-French introducer system couldnot be advanced to the abdominal aorta because of marked tortuosityof the iliac arteries and inadequate diameter of the externaliliac artery (<7 mm), requiring elective open surgical repair.
Figure 3. Implantation of a Bifurcated Graft in a 73-Year-Old Patient with an Infrarenal Abdominal Aortic Aneurysm.
In Panel A, an arteriogram with a calibrated catheter obtained before the procedure shows an infrarenal abdominal aortic aneurysm with involvement of the aortic bifurcation (type B aneurysm). In Panel B, an angiogram taken after the procedure shows the restored aortic lumen with complete exclusion of the aneurysmal sac. There is no leak at either end of the bifurcated endoprosthesis (arrows). In Panel C, follow-up computed tomography 12 months later confirms the exclusion of the aortic aneurysm by the absence of contrast enhancement within the aneurysmal sac. The diameter of the aneurysmal sac is virtually the same as it was before treatment. In Panel D, computed tomography at 24 months demonstrates that blood flow into the endoprosthesis remains good, with no evidence of a leak. The maximal diameter of the aneurysmal sac is now 5 mm smaller than it was at 12 months. In addition, the iliac limbs of the graft have shifted after thrombosis of the aneurysm.
Technical failure due to marked angulation of the proximal aneurysmalneck (>80 degrees) followed by dislodgment of the stent–graftand a proximal leak occurred in three patients. Because of thelarge diameter of the common iliac artery, three patients haddistal leaks from the lower end of the iliac limbs. Minor ormajor leaks related to tears in the polyester fabric occurredin the right or left iliac limb in eight patients immediatelyafter the procedure (Table 2).
In 17 patients, the iliac bifurcation had to be covered unilaterallywith an additional stent–graft to seal a distal leak.In one other patient we had to extend both iliac limbs withcovered nitinol stents. This resulted in obstruction of bothinternal iliac arteries without clinically affecting the pelvicor intestinal blood supply, and the aortic aneurysm thrombosedcompletely with no evidence of retrograde flow to the aneurysmthrough the internal iliac arteries.
The average length of time needed to implant the stent–graftwas 67±26 minutes in this group, with the entire proceduretaking an average of 105±31 minutes (range, 45 to 270).The average hospital stay was 11.5±13.1 days (range,4 to 83). As we gained more experience with the technique, theaverage hospital stay decreased to six days for the last 45patients.
Complications and Management
There were 13 minor and 3 major complications, including 1 perioperativedeath related to the intervention, in 16 patients (10 percent)(Table 3).
Table 3. Complications of Endoluminal Repair of Infrarenal Abdominal Aortic Aneurysms in 154 Patients.
Minor Complications
Clinically and angiographically evident macroembolization intoperipheral vessels was detected in three patients and successfullymanaged by local thrombolysis in one, aspiration thrombectomyin one, and Fogarty catheterization in one. Peripheral microembolizationof cholesterol to a toe was observed in one patient and treatedby intraarterial infusion of prostaglandin.
In two patients serum creatinine concentrations rose from 1.8and 2.1 mg per deciliter (160 and 185 µmol per liter)to 4.0 and 3.8 mg per deciliter (355 and 336 µmol perliter), respectively, requiring temporary hemodialysis.
Femoral-artery damage at the access site occurred in two patients.In both, the common femoral artery was heavily calcified andwas injured during advancement of the delivery system. Surgicalpatching of the artery was needed in both. Arteriovenous fistuladeveloped in one patient at the site of the percutaneous punctureand was surgically repaired. In one other patient who was receivinganticoagulation therapy a local hematoma developed at the puncturesite, requiring surgical intervention. Lymph fistulas were observedin two obese patients after surgical arteriotomy.
In one patient with occlusion of the left iliac limb within24 hours after the stent–graft procedure, local thrombolysiswith a total dose of 15 mg of recombinant tissue plasminogenactivator was successful.
Major Complications
In addition to the patient with rupture of the coiled externaliliac artery during the introduction of the delivery system,a patient with atrial fibrillation had embolic occlusion ofthe left limb of the graft four days after the procedure andcomplete occlusion of the aortic section two days later. Localthrombolysis resulted in complete resolution of the thrombus.This process was complicated, however, by microembolizationto the left foot, which ultimately required amputation.
One patient with cirrhosis of the liver (Child–Pugh classC) and a transjugular intrahepatic portosystemic stent–shuntplaced two years previously died of acute hepatic failure eightdays after the intervention because of massive bleeding froma gastric ulcer and hepatorenal syndrome.
Postimplantation Syndrome
Fever (temperature, 38.0 to 39.7°C) developed in 87 of the154 patients (56 percent) after treatment and lasted for 4 to10 days, without evidence of bacteremia or graft infection.In all patients, laboratory tests showed leukocytosis (range,9800 to 29,500 cells per cubic millimeter) and a mild or markedelevation of C-reactive protein concentrations (range, 4 to34.1 mg per deciliter).
Follow-Up
As of this writing, the average length of follow-up is 13 months(range, 8 days to 26 months). Five of 154 patients were followedfor 24 months, 66 for 12 months, 89 for 6 months, and 123 for3 months. There was only one death during the entire study period.
Patients with Straight Grafts
Two patients with minor persistent proximal leaks after dislodgmentof the stent and one patient with a major distal leak were successfullytreated 4 and 12 months, respectively, after the initial procedureby the placement of an additional straight graft (for the proximalleaks) or an overlapping bifurcated graft (for the distal leak).
Patients with Bifurcated Grafts
Follow-up studies in patients with bifurcated grafts revealedno migration of stent–grafts but a total of 11 persistentleaks. Three patients had a leak at the upper end of the graft;the leak thrombosed spontaneously in one patient and was correctedby the implantation of an additional short straight stent–graftin the other two patients. The three persistent leaks at thelower end of the stent–graft were successfully sealedby the implantation of an additional covered nitinol stent.Leaks related to tears in the polyester fabric thrombosed spontaneouslyin two of eight patients within seven days after the intervention.In four patients the tear was treated by placing a second coveredstent, resulting in complete thrombosis. The remaining two patientsdeclined further intervention.
Angiography at six months did not demonstrate any long-termocclusive disease of the external iliac arteries attributableto the placement of the delivery system.
Once the abdominal aortic aneurysm was excluded from the circulation,no further expansion of the aneurysmal sac was observed. Computedtomography of the infrarenal aorta demonstrated a reductionof 2 to 4 mm in the diameter of the aneurysmal sac at 12 months(Figure 3C), and a substantial shrinkage of 5 to 15 mm at 24months (Figure 3D). Circumscribed spontaneous reperfusion ofthe aneurysm from the right or left iliac limb was detectedin four patients at three and six months of follow-up. In addition,follow-up studies demonstrated minor late reperfusion of theaortic aneurysm with evidence of retrograde blood flow throughthe hypogastric and lumbar arteries in three patients. Theseleaks were successfully embolized with platinum coils.
Discussion
Elective surgical repair with synthetic grafts is the standardapproach to the treatment of abdominal aortic aneurysms andis associated with a perioperative mortality rate of 4 percent.4We evaluated stent–grafts placed percutaneously for thetreatment of abdominal aortic aneurysms as an alternative tomajor abdominal surgery. Becker et al. were the first to implanta covered stent into a subclavian aneurysm in humans.38 Theuse of a nonbifurcated stent–graft in patients with infrarenalaortic aneurysm was first reported by Parodi et al. in 1991.23The use of various stented or nonstented grafts for the endoluminalrepair of abdominal aortic aneurysm has been reported subsequently.24,25,26,27,29,31,32,33,34,35,36
Currently, there are five types of stent–grafts underclinical investigation. Parodi31 treated 50 patients with abdominalaortic aneurysms with nonbifurcated Dacron grafts sutured tostents with an expandable balloon, with a primary success rateof 80 percent and a 30-day mortality rate of 8 percent. Whiteet al.27 and May et al.28,32 used a nonstented balloon-expandablegraft consisting of a conventional Dacron graft with metallicimplants (Sydney endograft). They treated 53 patients with aorticaneurysms with straight grafts and a limited number of patientswith bifurcated grafts, with an initial success rate of 81 percent.The intervention was associated, however, with frequent local(32 percent) or systemic (17 percent) complications and a perioperativemortality rate of 3.7 percent.
The third type of stent–graft, designed by Chuter et al.,18consists of a Dacron sleeve anchored by stents at each end.It was implanted in 22 patients, with an initial success rateof 55 percent and a complication rate of 45 percent, includingone perioperative death.33
The only type of stent–graft approved by the Food andDrug Administration is the EVT device (Endovascular Technologies,Menlo Park, Calif.), composed of a Dacron tube with self-expandingcrowns at both ends for anchoring. Moore and Vescera29 and Balmet al.35 respectively treated 10 and 31 patients with infrarenalabdominal aortic aneurysms using straight grafts, with primarysuccess rates of 80 percent and 77 percent. The rate of localand systemic adverse effects was considerable, with one perioperativedeath and a total morbidity rate of 74 percent.35
In our study we implanted a fifth type of nonbifurcated or bifurcatedstent–graft based on a self-expandable nitinol frameworkcovered with a thin polyester fabric for the endovascular repairof abdominal aortic aneurysms. Our initial technical successrate in patients with type A, B, or C aneurysms was 87 percent.The rate of minor complications was 8 percent, the rate of majorcomplications was 2 percent, and the perioperative mortalityrate was 0.6 percent.
Incomplete sealing between the stent–graft and the aorta,defined as technical failure, was a major problem in our studygroup. Primary failure, which occurred in 13 percent of thepatients, was due to problems with access, to dislodgment ofthe stent–graft resulting in proximal leaks, to distalleaks from the lower end of the iliac limbs because the diameterof the common iliac artery was too large, or to leaks from theright or left iliac limb related to tears in the polyester fabric.Secondary failure with minor spontaneous reperfusion was observedin seven patients at three and six months and was due eitherto a tear in the polyester along the iliac limb or to reperfusionthrough the lumbar arteries. Technical failure was successfullytreated in all patients who agreed to the intervention, resultingin complete exclusion of the aortic aneurysm and restorationof normal blood flow and a secondary success rate of 97 percent.
In the series studied by Parodi,31 aneurysms generally decreasedin size by 10 to 20 percent during a mean follow-up of 17 monthsafter stent–graft implantation. In our study detailedcomputed tomographic measurements of the infrarenal aorta after6 and 12 months showed only slight reductions in the diameterof the aneurysmal sac, whereas in patients followed for 24 months,successful endoluminal treatment resulted in a substantial shrinkageof the aneurysm. In no case was an increase in the diameterof the aneurysmal sac observed during follow-up in patientswith initially successful exclusion of the abdominal aorticaneurysm.
At present, our main concern is the durability of stent–graftmaterial and the fixation system, which is crucial to the successof this endoluminal technique. Refinements of the stent frameworkand, particularly, its polyester fabric are now in progress.The enlargement of the diameter of the aortic section and theiliac limbs will potentially increase the number of patientsin whom this technique is appropriate.
In conclusion, on the basis of our initial results and a limitedfollow-up of an average of 13 months, endoluminal repair ofinfrarenal abdominal aortic aneurysms with the use of straightor bifurcated grafts is a feasible, safe, and effective alternativeto conventional surgery. Although we do not yet have extendedfollow-up data on the durability, safety, efficacy, and costsof stent–grafts, the approach may be a viable therapeuticoption, especially in patients at high surgical risk, and shouldbe evaluated in a prospective, randomized study comparing endoluminaland surgical repair to determine the clinical benefits of thisnew technique.39,40
We are indebted to Christian Schlensack, M.D., for providingthe laboratory data after stent–graft implantation, toUte Rogalski for her help in the preparation of the photographicreproductions, and to Helmut Müller for artwork.
Source Information
From the Departments of Diagnostic Radiology (U.B., M.L.) and Cardiovascular Surgery (F.B., G.S.), University Hospital, Freiburg, Germany; the Departments of Radiology (G.V., D.T.) and Surgery (G.N.), Henriettenstiftung, Hannover, Germany; and the Departments of Angiography and Interventional Radiology (J.L., S.T.) and Vascular Surgery (G.K., P.P., T.H.), University Hospital, Vienna, Austria.
Address reprint requests to Dr. Blum at the Department of Diagnostic Radiology, University Hospital Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany.
References
Dubost C, Allary M, Oeconomos N. Resection of an aneurysm of the abdominal aorta: reestablishment of the continuity by a preserved human arterial graft, with result after five months. Arch Surg 1952;64:405-408.
Creech O Jr. Endo-aneurysmorrhaphy and treatment of aortic aneurysms. Ann Surg 1966;164:935-946. [Medline]
Roger VL, Ballard DJ, Hallett JW Jr, Osmundson PJ, Puetz Pa, Gersh BJ. Influence of coronary artery disease on morbidity and mortality after abdominal aortic aneurysmectomy: a population-based study, 1971-1987. J Am Coll Cardiol 1989;14:1245-1252. [Abstract]
Ernst CB. Abdominal aortic aneurysm. N Engl J Med 1993;328:1167-1172. [Free Full Text]
Katz DJ, Stanley JC, Zelenock GB. Operative mortality rates for intact and ruptured abdominal aortic aneurysms in Michigan: an eleven-year statewide experience. J Vasc Surg 1994;19:804-817. [Medline]
Greenhalgh RM. Prognosis of abdominal aortic aneurysms. BMJ 1990;301:136-136.
Brown OW, Hollier LH, Pairolero PC, Kazmier FJ, McCready RA. Abdominal aortic aneurysm and coronary artery disease. Arch Surg 1981;116:1484-1488. [Free Full Text]
Crawford ES, Saleh SA, Babb JW III, Glaeser DH, Vaccaro PS, Silvers A. Infrarenal abdominal aortic aneurysm: factors influencing survival after operation performed over a 25-year period. Ann Surg 1981;193:699-709. [Medline]
Collin J, Araujo L, Walton J, Lindsell D. Oxford screening programme for abdominal aortic aneurysm in men aged 65 to 74 years. Lancet 1988;2:613-615. [Medline]
Scott RAP, Ashton HA, Kay DN. Abdominal aortic aneurysm in 4237 screened patients: prevalence, development and management over 6 years. Br J Surg 1991;78:1122-1125. [Medline]
Dotter CT. Transluminally-placed coilspring endarterial tube grafts: long-term patency in canine popliteal artery. Invest Radiol 1969;4:329-332. [Medline]
Balko A, Piasecki GJ, Shah DM, Carney WI, Hopkins RW, Jackson BT. Transfemoral placement of intraluminal polyurethane prosthesis for abdominal aortic aneurysm. J Surg Res 1986;40:305-309. [CrossRef][Medline]
Palmaz JC, Sibbitt RR, Tio FO, Reuter SR, Peters JE, Garcia F. Expandable intraluminal vascular graft: a feasibility study. Surgery 1986;99:199-205. [Medline]
Lawrence DD Jr, Charnsangavej C, Wright KC, Gianturco C, Wallace S. Percutaneous endovascular graft: experimental evaluation. Radiology 1987;163:357-360. [Free Full Text]
Yoshioka T, Wright KC, Wallace S, Lawrence DD Jr, Gianturco C. Self-expandable endovascular graft: an experimental study in dogs. AJR Am J Roentgenol 1988;151:673-676. [Free Full Text]
Mirich D, Wright KC, Wallace S, et al. Percutaneously placed endovascular grafts for aortic aneurysms: feasibility study. Radiology 1989;170:1033-1037. [Free Full Text]
Laborde JC, Parodi JC, Clem MF, et al. Intraluminal bypass of abdominal aortic aneurysm: feasibility study. Radiology 1992;184:185-190. [Free Full Text]
Chuter TAM, Green RM, Ouriel K, Fiore WM, DeWeese JA. Transfemoral endovascular aortic graft placement. J Vasc Surg 1993;18:185-197. [CrossRef][Medline]
Boudghene FS, Anidjar S, Allaire E, Osborne-Pellegrin M, Bigot JM, Michel JB. Endovascular grafting in elastase-induced experimental aortic aneurysms in dogs: feasibility and preliminary results. J Vasc Interv Radiol 1993;4:497-504. [Medline]
Hagen B, Harnoss BM, Trabhardt S, Ladeburg M, Fuhrmann H, Franck C. Self-expandable macroporous nitinol stents for transfemoral exclusion of aortic aneurysms in dogs: preliminary results. Cardiovasc Intervent Radiol 1993;16:339-342. [Medline]
Piquet P, Rolland PH, Bartoli JM, Tranier P, Moulin G, Mercier C. Tantalum-Dacron coknit stent for endovascular treatment of aortic aneurysms: a preliminary experimental study. J Vasc Surg 1994;19:698-706. [Medline]
Ruiz CE, Zhang HP, Douglas JT, Zuppan CW, Kean CJC. A novel method for treatment of abdominal aortic aneurysms using percutaneous implantation of a newly designed endovascular device. Circulation 1995;91:2470-2477. [Free Full Text]
Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5:491-499. [CrossRef][Medline]
Volodos NL, Karpovich IP, Troyan VI, et al. Clinical experience of the use of self-fixing synthetic prostheses for remote endoprosthetics of the thoracic and the abdominal aorta and iliac arteries through the femoral artery and as intraoperative endoprosthesis for aorta reconstruction. Vasa Suppl 1991;33:93-95. [Medline]
Scott RAP, Chuter TAM. Clinical endovascular placement of bifurcated graft in abdominal aortic aneurysms without laparotomy. Lancet 1994;343:413-413. [Medline]
Yusuf SW, Baker DM, Chuter TAM, Whitaker SC, Wenham PW, Hopkinson BR. Transfemoral endoluminal repair of abdominal aortic aneurysm with bifurcated graft. Lancet 1994;344:650-651. [CrossRef][Medline]
White GH, Yu W, May J, Stephen MS, Waugh RC. A new nonstented balloon-expandable graft for straight or bifurcated endoluminal bypass. J Endovasc Surg 1994;1:16-24. [CrossRef][Medline]
May J, White GH, Yu W, et al. Endoluminal grafting of abdominal aortic aneurysms: causes of failure and their prevention. J Endovasc Surg 1994;1:44-52. [CrossRef][Medline]
Moore WS, Vescera CL. Repair of abdominal aortic aneurysm by transfemoral endovascular graft placement. Ann Surg 1994;220:331-341. [Medline]
Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729-1734. [Free Full Text]
Parodi JC. Endovascular repair of abdominal aortic aneurysms and other arterial lesions. J Vasc Surg 1995;21:549-557. [CrossRef][Medline]
May J, White GH, Yu W, et al. Surgical management of complications following endoluminal grafting of abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 1995;10:51-59. [CrossRef][Medline]
Chuter TAM, Wendt G, Hopkinson BR, et al. Transfemoral insertion of a bifurcated endovascular graft for aortic aneurysm repair: the first 22 patients. Cardiovasc Surg 1995;3:121-128. [Medline]
Blum U, Langer M, Spillner G, et al. Abdominal aortic aneurysms: preliminary technical and clinical results with transfemoral placement of endovascular self-expanding stent-grafts. Radiology 1996;198:25-31. [Free Full Text]
Balm R, Eikelboom BC, May J, Bell PR, Swedenborg J, Collin J. Early experience with transfemoral endovascular aneurysm management (TEAM) in the treatment of aortic aneurysms. Eur J Vasc Endovasc Surg 1996;11:214-220. [CrossRef][Medline]
Murphy KD, Richter GM, Henry M, Encarnacion CE, Le VA, Palmaz JC. Aortoiliac aneurysms: management with endovascular stent-graft placement. Radiology 1996;198:473-480. [Free Full Text]
Cragg AH, De Jong SC, Barnhart WH, Landas SK, Smith TP. Nitinol intravascular stent: results of preclinical evaluation. Radiology 1993;189:775-778. [Free Full Text]
Becker GJ, Benenati JF, Zemel G, et al. Percutaneous placement of a balloon-expandable intraluminal graft for life-threatening subclavian arterial hemorrhage. J Vasc Interv Radiol 1991;2:225-229. [Medline]
Porter JM. Endovascular arterial intervention: expression of concern. J Vasc Surg 1995;21:995-997. [CrossRef][Medline]
White GH, May J, McGahan T, et al. Historic control comparison of outcome for matched groups of patients undergoing endoluminal versus open repair of abdominal aortic aneurysms. J Vasc Surg 1996;23:201-212. [CrossRef][Medline]
Infrarenal Aortic Aneurysms
Matsumura J. S., Pearce W. H., Yusuf S. W., Wenham P., Hopkinson B. R., Hoch R. C., Blum U., Beyersdorf F., Ernst C. B.
Extract |
Full Text
N Engl J Med 1997;
336:1756-1758, Jun 12, 1997.
Correspondence
This article has been cited by other articles:
Stolzmann, P., Frauenfelder, T., Pfammatter, T., Peter, N., Scheffel, H., Lachat, M., Schmidt, B., Marincek, B., Alkadhi, H., Schertler, T.
(2008). Endoleaks after Endovascular Abdominal Aortic Aneurysm Repair: Detection with Dual-Energy Dual-Source CT. Radiology
249: 682-691
[Abstract][Full Text]
Hong, C., Heiken, J. P., Sicard, G. A., Pilgram, T. K., Bae, K. T.
(2008). Clinical Significance of Endoleak Detected on Follow-Up CT After Endovascular Repair of Abdominal Aortic Aneurysm. Am. J. Roentgenol.
191: 808-813
[Abstract][Full Text]
Holfeld, J., Gottardi, R., Zimpfer, D., Dorfmeister, M., Dumfarth, J., Funovics, M., Schoder, M., Weigang, E., Lammer, J., Wolner, E., Czerny, M., Grimm, M.
(2008). Treatment of Symptomatic Coral Reef Aorta by Endovascular Stent-Graft Placement. Ann. Thorac. Surg.
85: 1817-1819
[Abstract][Full Text]
Rowlands, T. E., Homer-Vanniasinkam, S.
(2007). Paradoxical Neutrophil Elastase Release in Endovascular Abdominal Aortic Aneurysm Repair. VASC ENDOVASCULAR SURG
41: 48-54
[Abstract]
Leurs, L. J., Buth, J., Laheij, R. J. F., for the EUROSTAR Collaborators,
(2007). Long-term Results of Endovascular Abdominal Aortic Aneurysm Treatment With the First Generation of Commercially Available Stent Grafts. Arch Surg
142: 33-41
[Abstract][Full Text]
Norwood, M G A, Lloyd, G M, Bown, M J, Fishwick, G, London, N J, Sayers, R D
(2007). Endovascular abdominal aortic aneurysm repair. Postgrad. Med. J.
83: 21-27
[Abstract][Full Text]
Yang, J., Zuo, J., Yang, L., Duan, W., Xiong, L., Zheng, M., Cui, H., Yi, D.
(2006). Endovascular stent-graft treatment of thoracic aortic dissection. ICVTS
5: 688-691
[Abstract][Full Text]
Gerasimidis, T., Sfyroeras, G., Trellopoulos, G., Skoura, L., Papazoglou, K., Konstantinidis, K., Karamanos, D., Filaktou, A., Parapanisiou, E.
(2005). Impact of Endograft Material on the Inflammatory Response After Elective Endovascular Abdominal Aortic Aneurysm Repair. ANGIOLOGY
56: 743-753
[Abstract]
Duebener, L. F., Lorenzen, P., Richardt, G., Misfeld, M., Notzold, A., Hartmann, F., Sievers, H.-H., Geist, V.
(2004). Emergency Endovascular Stent-Grafting for Life-Threatening Acute Type B Aortic Dissections. Ann. Thorac. Surg.
78: 1261-1266
[Abstract][Full Text]
Elkouri, S., Martelli, E., Gloviczki, P., McKusick, M. A., Panneton, J. M., Andrews, J. C., Noel, A. A., Bower, T. C., Sullivan, T. M., Rowland, C., Hoskin, T. L., Cherry, K. J.
(2004). Most Patients with Abdominal Aortic Aneurysm Are Not Suitable for Endovascular Repair Using Currently Approved Bifurcated Stent-Grafts. VASC ENDOVASCULAR SURG
38: 401-412
[Abstract]
Nataraj, V, Mortimer, A.
(2004). Endovascular abdominal aortic aneurysm repair. Contin Educ Anaesth Crit Care Pain
4: 91-94
[Abstract][Full Text]
Elkouri, S., Gloviczki, P., McKusick, M. A., Panneton, J. M., Andrews, J. C., Bower, T. C., Noel, A. A., Sullivan, T. M., Canton, L. G., Harmsen, W. S., Hoskin, T. L., Cherry, K. J.
(2003). Endovascular Repair of Abdominal Aortic Aneurysms: Initial Experience With 100 Consecutive Patients. Mayo Clin Proc.
78: 1234-1242
[Abstract]
Santamore, D. C., Saldanha, C. L., Santamore, W. P.
(2003). Endovascular Repair of the Abdominal Aortic Aneurysm. SEMIN CARDIOTHORAC VASC ANESTH
7: 213-222
[Abstract]
Rozenblit, A. M., Patlas, M., Rosenbaum, A. T., Okhi, T., Veith, F. J., Laks, M. P., Ricci, Z. J.
(2003). Detection of Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysm: Value of Unenhanced and Delayed Helical CT Acquisitions. Radiology
227: 426-433
[Abstract][Full Text]
Schoder, M., Cartes-Zumelzu, F., Grabenwoger, M., Cejna, M., Funovics, M., Krenn, C. G., Hutschala, D., Wolf, F., Thurnher, S., Kretschmer, G., Lammer, J.
(2003). Elective Endovascular Stent-Graft Repair of Atherosclerotic Thoracic Aortic Aneurysms:Clinical Results and Midterm Follow-Up. Am. J. Roentgenol.
180: 709-715
[Abstract][Full Text]
Maldonado, T. S., Gagne, P. J.
(2003). Controversies in the Management of Type 11 "Branch" Endoleaks Following Endovascular Abdominal Aortic Aneurysm Repair. VASC ENDOVASCULAR SURG
37: 1-12
[Abstract]
Moffatt, S. D., Mitchell, R. S.
(2003). Endovascular Stent Management of Thoracic Aneurysms and Dissections. Card Surg Adult
2: 1191-1204
[Full Text]
Teufelsbauer, H., Prusa, A. M., Wolff, K., Polterauer, P., Nanobashvili, J., Prager, M., Holzenbein, T., Thurnher, S., Lammer, J., Schemper, M., Kretschmer, G., Huk, I.
(2002). Endovascular Stent Grafting Versus Open Surgical Operation in Patients With Infrarenal Aortic Aneurysms: A Propensity Score-Adjusted Analysis. Circulation
106: 782-787
[Abstract][Full Text]
Lachat, M., Pfammatter, T., Witzke, H., Bernard, E., Wolfensberger, U., Kunzli, A., Turina, M.
(2002). Acute traumatic aortic rupture: early stent-graft repair. Eur. J. Cardiothorac. Surg.
21: 959-963
[Abstract][Full Text]
Hutschala, D., Fleck, T., Czerny, M., Ehrlich, M., Schoder, M., Lammer, J., Wolner, E., Grabenwoger, M.
(2002). Endoluminal stent-graft placement in patients with acute aortic dissection type B. Eur. J. Cardiothorac. Surg.
21: 964-969
[Abstract][Full Text]
Golzarian, J., Murgo, S., Dussaussois, L., Guyot, S., Said, K. A., Wautrecht, J. C., Struyven, J.
(2002). Evaluation of Abdominal Aortic Aneurysm After Endoluminal Treatment: Comparison of Color Doppler Sonography with Biphasic Helical CT. Am. J. Roentgenol.
178: 623-628
[Abstract][Full Text]
Quinn, S. F., Kim, J., Sheley, R. C., Demlow, T. A., Zelko, J.
(2002). Percutaneous Deployment of a Low-Profile Bifurcated Stent-Graft. Am. J. Roentgenol.
178: 654-656
[Full Text]
Howell, M. H., Strickman, N., Mortazavi, A., Hallman, C. H., Krajcer, Z.
(2001). Preliminary results of endovascular abdominal aortic aneurysm exclusion with the AneuRx stent-graft. J Am Coll Cardiol
38: 1040-1046
[Abstract][Full Text]
White, C. J
(2001). Non-surgical treatment of patients with peripheral vascular disease. Br Med Bull
59: 173-192
[Abstract][Full Text]
Sangiorgi, G., D'Averio, R., Mauriello, A., Bondio, M., Pontillo, M., Castelvecchio, S., Trimarchi, S., Tolva, V., Nano, G., Rampoldi, V., Spagnoli, L. G., Inglese, L.
(2001). Plasma Levels of Metalloproteinases-3 and -9 as Markers of Successful Abdominal Aortic Aneurysm Exclusion After Endovascular Graft Treatment. Circulation
104
: I-288-I-295
[Abstract][Full Text]
Schoder, M., Zaunbauer, L., Holzenbein, T., Fleischmann, D., Cejna, M., Kretschmer, G., Thurnher, S., Lammer, J.
(2001). Internal Iliac Artery Embolization Before Endovascular Repair of Abdominal Aortic Aneurysms: Frequency, Efficacy, and Clinical Results. Am. J. Roentgenol.
177: 599-605
[Abstract][Full Text]
Bosch, J. L., Beinfeld, M. T., Halpern, E. F., Lester, J. S., Gazelle, G. S.
(2001). Endovascular versus Open Surgical Elective Repair of Infrarenal Abdominal Aortic Aneurysm: Predictors of Patient Discharge Destination. Radiology
220: 576-580
[Abstract][Full Text]
Bosch, J. L., Lester, J. S., McMahon, P. M., Beinfeld, M. T., Halpern, E. F., Kaufman, J. A., Brewster, D. C., Gazelle, G. S.
(2001). Hospital Costs for Elective Endovascular and Surgical Repairs of Infrarenal Abdominal Aortic Aneurysms. Radiology
220: 492-497
[Abstract][Full Text]
Silberzweig, J. E., Marin, M. L., Hollier, L. H., Mitty, H. A., Connelly, T. L.
(2001). Balloon-Expandable Common Iliac Artery Occluder Device for Endovascular Aneurysm Repair. VASC ENDOVASCULAR SURG
35: 263-271
[Abstract]
Sawhney, R., Kerlan, R. K., Wall, S. D., Chuter, T. A. M., Ruiz, D. E., Canto, C. J., LaBerge, J. M., Reilly, L. M., Yee, J., Wilson, M. W., Jean-Claude, J., Faruqi, R. M., Gordon, R. L.
(2001). Analysis of Initial CT Findings after Endovascular Repair of Abdominal Aortic Aneurysm. Radiology
220: 157-160
[Abstract][Full Text]
Görich, J., Rilinger, N., Sokiranski, R., Söldner, J., Kaiser, W., Krämer, S., Ermis, C., Schütz, A., Sunder-Plassmann, L., Pamler, R.
(2001). Endoleaks after Endovascular Repair of Aortic Aneurysm: Are They Predictable?--Initial Results. Radiology
218: 477-480
[Abstract][Full Text]
Zaugg, M., Lachat, M. L., Pfammatter, T., Cathomas, G., Schmid, E. R.
(2001). Sudden Respiratory Arrest Resulting From Brainstem Embolism in a Patient Undergoing Endovascular Abdominal Aortic Aneurysm Repair. Anesth. Analg.
92: 335-337
[Abstract][Full Text]
Yano, O. J., Marin, M. L., Hollier, L.
(2001). Endovascular Options in the Management of Complex Aortic Problems. PERSPECT VASC SURG ENDOVASC THER
14: 1-12
[Abstract]
Storck, M., Scharrer-Pamler, R., X, K., Gallmeier, U., Gorich, J., Sunder-Plassmann, L., Bruckner, U., Mickley, V.
(2001). Does a Postimplantation Syndrome Following Endovascular Treatment of Aortic Aneurysms Exist?. VASC ENDOVASCULAR SURG
35: 23-29
[Abstract]
Czermak, B. V., Waldenberger, P., Fraedrich, G., Dessl, A. H., Roberts, K. E., Bale, R. J., Perkmann, R., Jaschke, W. R.
(2000). Treatment of Stanford Type B Aortic Dissection with Stent-Grafts: Preliminary Results. Radiology
217: 544-550
[Abstract][Full Text]
Lammer, J., Dake, M. D., Bleyn, J., Katzen, B. T., Cejna, M., Piquet, P., Becker, G. J., Settlage, R. A.
(2000). Peripheral Arterial Obstruction: Prospective Study of Treatment with a Transluminally Placed Self-expanding Stent-Graft. Radiology
217: 95-104
[Abstract][Full Text]
Kaufman, J. A., Geller, S. C., Brewster, D. C., Fan, C.-M., Cambria, R. P., LaMuraglia, G. M., Gertler, J. P., Abbott, W. M., Waltman, A. C.
(2000). Endovascular Repair of Abdominal Aortic Aneurysms: Current Status and Future Directions. Am. J. Roentgenol.
175: 289-302
[Full Text]
Görich, J., Rilinger, N., Sokiranski, R., Krämer, S. C., Ermis, C., Schütz, A., Brambs, H.-J., Söldner, J., Kaiser, W., Sunder-Plassmann, L., Pamler, R.
(2000). Treatment of Leaks after Endovascular Repair of Aortic Aneurysms. Radiology
215: 414-420
[Abstract][Full Text]
Ishiguchi, T., Nishikimi, N., Usui, A., Ishigaki, T.
(2000). Endovascular Stent-Graft Deployment: Temporary Vena Caval Occlusion with Balloons to Control Aortic Blood Flow-Experimental Canine Study and Initial Clinical Experience. Radiology
215: 594-599
[Abstract][Full Text]
Doenst, T., Schlensak, C., Beyersdorf, F., Rousseau, H., Janne d’Othee, B., Perreault, P., Meites, G., Joffre, F., Otal, P., Soula, P., Concina, P., Massabuau, P., Mazerolles, M., Bui, B.
(2000). Limitations to the Therapeutic Potential of Endoluminal Stent Placement in the Thoracic Aorta • Response. Circulation
101
: e96-e96
[Full Text]
Gorich, J., Rilinger, N., Kramer, S., Sokiranski, R., Pamler, R., Ermis, C., Kapfer, X.
(2000). Angiography of Leaks After Endovascular Repair of Infrarenal Aortic Aneurysms. Am. J. Roentgenol.
174: 811-814
[Abstract][Full Text]
Makaroun, M., Zajko, A.
(2000). Endoleaks Following Endovascular Aortic Aneurysm Repair: Clinical Significance and Treatment Modalities. PERSPECT VASC SURG ENDOVASC THER
13: 1-14
[Abstract]
Bali, H. K, Jain, A. K
(1999). Takayasu's Arteritis: Current Status of Angioplasty and Stenting. Asian Cardiovasc. Thorac. Ann.
7: 339-344
[Abstract][Full Text]
Haskal, Z. J., Brennecke, L. H.
(1999). Transjugular Intrahepatic Portosystemic Shunts Formed with Polyethylene Terephthalate-covered Stents: Experimental Evaluation in Pigs. Radiology
213: 853-859
[Abstract][Full Text]
Inoue, K., Hosokawa, H., Iwase, T., Sato, M., Yoshida, Y., Ueno, K., Tsubokawa, A., Tanaka, T., Tamaki, S., Suzuki, T.
(1999). Aortic Arch Reconstruction by Transluminally Placed Endovascular Branched Stent Graft. Circulation
100
: II-316-II-321
[Abstract][Full Text]
Smith, B. M., Gray, R. J., Laird, J. R., Kohlman-Trigoboff, D., Deforty, D., Stanford, J. L.
(1999). Management of the Femoral Artery After Transluminal Repair of Abdominal Aortic Aneurysms. VASC ENDOVASCULAR SURG
33: 589-593
[Abstract]
Nienaber, C. A., Fattori, R., Lund, G., Dieckmann, C., Wolf, W., von Kodolitsch, Y., Nicolas, V., Pierangeli, A.
(1999). Nonsurgical Reconstruction of Thoracic Aortic Dissection by Stent-Graft Placement. NEJM
340: 1539-1545
[Abstract][Full Text]
Dake, M. D., Kato, N., Mitchell, R. S., Semba, C. P., Razavi, M. K., Shimono, T., Hirano, T., Takeda, K., Yada, I., Miller, D. C.
(1999). Endovascular Stent-Graft Placement for the Treatment of Acute Aortic Dissection. NEJM
340: 1546-1552
[Abstract][Full Text]
Rousseau, H., Soula, P., Perreault, P., Bui, B., d'Othee, B. J., Massabuau, P., Meites, G., Concina, P., Mazerolles, M., Joffre, F., Otal, P.
(1999). Delayed Treatment of Traumatic Rupture of the Thoracic Aorta With Endoluminal Covered Stent. Circulation
99: 498-504
[Abstract][Full Text]
Svensson, L. G., Cambria, R. P.
(1998). Expanding Surgical Options Using Minimally Invasive Techniques for Cardio-aortic and Aortic Procedures. Arch Surg
133: 1160-1165
[Abstract][Full Text]
Goldman, L.
(1998). A 75-Year-Old Woman With an Abdominal Aortic Aneurysm and Emphysema. JAMA
280: 366-372
[Full Text]
Ahn, S. S., Obrand, D. I.
(1998). Current Status of Intraluminal Grafts for Aortic Aneurysms. VASC ENDOVASCULAR SURG
32: 215-219
Matsumura, J. S., Pearce, W. H., Yusuf, S. W., Wenham, P., Hopkinson, B. R., Hoch, R. C., Blum, U., Beyersdorf, F., Ernst, C. B.
(1997). Infrarenal Aortic Aneurysms. NEJM
336: 1756-1758
[Full Text]
(1997). ENDOVASCULAR STENT-GRAFTS FOR ABDOMINAL AORTIC ANEURYSMS. JWatch General
1997: 4-4
[Full Text]
Ernst, C. B.
(1997). Current Therapy for Infrarenal Aortic Aneurysms. NEJM
336: 58-60
[Full Text]
Pitton, M. B., Schmenger, R. P., Neufang, A., Konerding, M. A., Duber, C., Thelen, M.
(2002). Endovascular Aneurysm Repair: Magnetic Resonance Monitoring of Histological Organization Processes in the Excluded Aneurysm. Circulation
105: 1995-1999
[Abstract][Full Text]
Previous
