DOI:10.2214/AJR.04.1881
AJR 2006; 186:1144-1147
© American Roentgen Ray Society
Endovascular Repair of Inflammatory Aortic Aneurysms: Long-Term Results
Stefan Puchner1,
Robert A. Bucek1,
Christian Loewe1,
Thomas Hoelzenbein2,
Georg Kretschmer2,
Markus Reiter3 and
Johannes Lammer1
1 Department of Angiography and Interventional Radiology, Medical University of
Vienna, Waehringer Guertel 18-20, Vienna, Austria 1090.
2 Department of Vascular Surgery, Medical University of Vienna, Vienna, Austria
1090.
3 Zentralröntgeninstitut, KA Rudolfstiftung, Vienna, Austria.
Received December 15, 2004;
accepted after revision February 9, 2005.
Address correspondence to R. A. Bucek.
Abstract
OBJECTIVE. Our objective was to report the long-term follow-up
results of endovascular aneurysm repair of inflammatory aortic aneurysms.
CONCLUSION. Endovascular aneurysm repair of inflammatory aortic
aneurysms excludes the aneurysm and seems to reduce the size of the aneurysmal
sac and the extent of periaortic fibrosis with acceptable periinterventional
and long-term morbidity.
Keywords: aortic aneurysm • endovascular repair • follow-up • inflammation • long-term • stent-graft
Introduction
Aortic aneurysms account for more than 15,000 deaths in the United States
annually and affect an estimated 5-7% of people 60 years or older
[1]. Although atherosclerosis
plays the main role in the pathogenesis, inflammatory aortic aneurysms present
a minor subgroup, with an incidence ranging from 2.2-18.1% of the total number
of abdominal aortic aneurysms
[2]. Although the standard
treatment of all aortic aneurysms still remains open surgical repair,
endovascular aneurysm repair has shown promising early and midterm results
[3-5].
Endovascular repair may be a more appropriate treatment option for
high-risk patients such as those suffering from inflammatory aortic aneurysms.
The perioperative mortality associated with open surgical repair of
inflammatory aortic aneurysms is three times higher than that with
noninflammatory aortic aneurysms, largely due to the intraoperative technical
difficulties related to inflammation, such as periaortic fibrosis
[6-9].
Some studies and case reports have proposed that endovascular aneurysm repair
can reduce this increased risk of complications with equally good results in
aneurysm exclusion and aneurysm rupture prevention
[3].
Because the literature provides little information about the mid- and
long-term outcome of inflammatory aortic aneurysms for patients treated by
endovascular aneurysm repair, we performed a retrospective analysis to
evaluate our results, with a special focus on aneurysm diameter, aortic and
periaortic inflammation, renal impairment, and procedure-related and long-term
complications.
Materials and Methods
Patient Selection
We performed a retrospective cohort analysis that included all consecutive
patients who underwent endovascular aneurysm repair between January 1995 and
March 2004 by reviewing the local electronic radiologic information system
(Magic SAS, Siemens Austria) and our records of endovascular procedures.
During that time, 296 patients with abdominal aortic aneurysm disease were
treated by endovascular aneurysm repair. Eight patients (2.7%) were identified
as having an inflammatory aortic aneurysm. All patients were men and had a
median age of 68.5 years (range, 55-82 years).
Endovascular Aneurysm Repair
Endovascular aneurysm repair was performed under spinal anesthesia
(supported by the local department of anesthesiology) by a uni- or bifemoral
approach. Commercially available modular stent-grafts were implanted through
the common femoral artery after preparation or arteriotomy performed by
vascular surgeons. Intraluminal positioning and deployment of all stent-grafts
took place under fluoroscopic guidance in an endovascular suite (Multistar,
Polytron Top; Siemens Medical Solutions).
Imaging
Contrast-enhanced helical CT angiography was performed before the
intervention, within 1 week after endovascular aneurysm repair, and then in
intervals of 6 months or 1 year. Images were reviewed on a PACS workstation
(AGFA Merst) for signs of inflammatory aortic aneurysms as morphologically
described by Walker et al.
[10]: a thickened aneurysm
wall accompanied by a dense fibrosis involving adjacent structures such as the
duodenum, ureters, and inferior vena cava. Then, follow-up images of these
patients were identified and reviewed by two observers in consensus who
focused on the following outcome parameters: the maximal aneurysm diameter (in
mm), the degree of periaortic fibrosis (semiquantitive assessment using the
method of Arrive et al. [11],
which classifies the fibrosis as disappeared, reduced, remained unchanged, or
progressed), renal pathologies such as hydronephrosis or renal atrophy,
potential stent-graft migration, and the success of aneurysm exclusion
(presence or absence of endoleaks). We also evaluated all procedure-related
complications and the 30-day and long-term mortality rates.
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Fig. 1C —CT angiography images of patient number 3, 67-year-old man. Image
levels are focused on maximum diameter of aneurysm sac. Final follow-up
examination 65 months after endovascular aneurysm repair. Note remarkable
reduction of aneurysm sac and complete disappearance of periaortic fibrosis on
corresponding axial slices indicated by large vertebral osteophyte.
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Data Presentation
All numeric values are stated as the median with minimum and maximum in
parentheses.
Results
Aneurysm exclusion with bifurcated stent-grafts was primarily successful in
all patients, and no complications occurred during the intervention. In one
patient, a thrombotic occlusion of a leg of the Y stent-graft occurred 2 days
after the intervention and was successfully treated by local intraarterial
fibrinolysis through a left-sided axillary catheter. The first
postinterventional CT angiography scan (median 5, days after intervention;
range, 3-7 days) showed no dislocation of the stent-graft and no extravasation
of contrast medium in the aneurysm sac as a result of endoleak in any of the
patients. The 30-day mortality rate was 0%.
Median radiologic follow-up of the entire study group was 24 months (range,
1-109 months). One patient was lost to follow-up after the 1-month CT
angiography. One patient died 9 months after the intervention as a result of
multiorgan failure and shock 1 month after an emergency laparotomy due to a
necrotic pancreatitis. Another patient died 23 months after the intervention
because of acute respiratory distress syndrome resulting from aspiration
pneumonia. In these three patients, the last CT angiography showed neither
significant change of the aneurysm diameter and the periaortic fibrosis nor a
dislocation of the stent-graft and no endoleak.
In the remaining five patients, the minimum follow-up period was 36 months.
The maximum diameter of the aneurysm sacs decreased from a median of 57 mm
(range, 47-95 mm) to a median of 45 mm (range, 36-60 mm), resulting in a
median relative regression of 21.1% (range, 4.8-63.1%). Representative
preinterventional, early postinterventional, and late postinterventional CT
angiography images of patient 3 are shown in Figures
1A,
1B, and
1C. In all patients, periaortic
fibrosis regressed during the follow-up period. In three patients, it
disappeared completely as did the enhancement of the aortic wall. In two
patients, hydronephrosis was observed primarily as a result of the compression
of the ureter due to the periaortic fibrosis. In one of the patients, the
ureteral obstruction disappeared completely 6 years after the intervention,
and the ureteral stent could be removed (Figs.
2A and
2B). In the other patient, the
hydronephrosis remained unchanged.
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Fig. 2A —CT angiography images of patient number 8, 70-year-old man. First
examination after endovascular aneurysm repair. Note extensive periaortic
fibrosis, enhancement of aortic wall, and hydronephrosis on right side.
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Fig. 2B —CT angiography images of patient number 8, 70-year-old man. Final
follow-up examination 109 months after endovascular aneurysm repair. Note
complete disappearance of aortic and periaortic inflammation and
hydronephrosis on corresponding axial slices.
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Two years after the intervention, all aneurysms were still excluded. Mid-
and long-term complications occurred in two patients because of a type III
endoleak (dislocation of the contralateral limb of the Vanguard stent-graft
[Boston Scientific]) that was successfully overstented. In both patients, the
endoleak occurred twice, at intervals of 4 and 5 years in the first patient
and at 2 and 9 years after the intervention in the second patient. Detailed
results for all included patients are shown in
Table 1.
Discussion
The literature provides little information about the long-term results of
endovascular aneurysm repair in patients suffering from inflammatory aortic
aneurysms. The particularity of inflammatory aortic aneurysms lies in
diagnosis and therapy. Its exact definition is still debatable, and we
included in our study only patients who fulfilled the inflammatory criteria
described by Walker et al.
[10].
The hypothesis of this study, based on the results of previous studies
[12-14],
was the presumption that endovascular aneurysm repair of inflammatory aortic
aneurysms is a safe alternative to open surgical repair because it has a low
perioperative risk and a low complication rate. These studies have shown that
endovascular aneurysm repair has less frequent and less severe intraoperative
cardiac and pulmonary complications (11% vs 22% and 3% vs 16%, respectively),
especially in high-risk patients. The trade-off is seen in the high
reintervention rate. Reintervention is often necessary because of
graft-related complications (13% vs 4%)
[12-14].
In our study, we observed type III endoleaks in two patients that necessitated
two reinterventions for overstenting. We think the main explanation for this
high rate of type III endoleaks was the design of the stent-grafts used
(Vanguard); however, this stent-graft design has been withdrawn from the
market.
Open surgical repair of inflammatory aortic aneurysms is intrinsically
accompanied by a higher complication and mortality rate compared with open
surgical repair of noninflammatory aortic aneurysms because of the technical
complications caused by inflammation and fibrosis
[6-9].
The surgical challenge lies in the difficulty of the dissection and control of
the proximal and distal aorta, which leads to a three-times-higher
perioperative morbidity and mortality rate (7.9% vs 2.4%), especially when
ureterolysis is performed in cases of associated hydronephrosis
[9,
15]. In our study, we observed
one procedure-related complication, which was successfully treated by
intraarterial fibrinolysis, resulting in a 12.5% morbidity rate and a 0%
mortality rate within the first 30 postinterventional days.
Our results in aneurysm exclusion were rather satisfying. The maximum
diameter of the aneurysm sac showed a median regression of 6% including all
patients in this analysis, but these results are improved to a median
regression of 21% if patients are assessed with a minimum follow-up of 2
years.
The cause of inflammatory aortic aneurysms remains unclear. It is not
certain whether they have an independent pathogenesis or represent a subset of
the wide spectrum of inflammatory changes present in all aortic aneurysms
[9,
16]. The effect of the
intervention on the inflammatory process is also unclear. In fact, either
technique, endovascular aneurysm repair or open surgical repair, can provoke
an inflammatory response due to cytokine release. However, this cytokine
response seems to be greater during open surgical repair than endovascular
aneurysm repair [17]. One
study has not only concluded that endovascular aneurysm repair failed to treat
periaortic fibrosis but also suggested that the technique may be associated
with de novo development of periaortic fibrosis
[18].
In contrast, Hinchliffe et al.
[3] reported a regression of
periaortic fibrosis in three of six patients (50%) and an unchanged situation
in the remaining three. We observed even better results, with a regression of
the inflammatory tissue and the periaortic fibrosis in all five patients and a
complete disappearance in three of them after endovascular aneurysm repair
[3]. On the other hand, open
surgical repair of inflammatory aortic aneurysms shows only moderate results
in the regression of inflammatory tissue. Two studies have reported no
significant change in periaortic fibrosis in about two-thirds of patients
undergoing open surgical repair
[19,
20]. These facts enforce
endovascular aneurysm repair as an attractive alternative with better results
in the regression of periaortic fibrosis.
The conclusions of our study are limited by the relatively small number of
patients because of the rare occurrence of inflammatory aortic aneurysms. Our
analysis revealed that endovascular aneurysm repair is an effective method for
the management of inflammatory aortic aneurysms. It results in a satisfactory
exclusion of the aneurysm and a reduction of the aneurysm sac as well as of
aortic and periaortic inflammation, and is associated with an acceptable
periinterventional and delayed complication rate. Therefore, it may represent
an attractive alternative to open surgical repair.
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Abstract
Introduction
