COMPLEMENTARY SURGICAL INTERVENTIONAL TECHNIQUES FOR NONRESECTIVE MANAGEMENT OF INOPERABLE ANEURYSMS - A 2ND LOOK/

Induced thrombosis (''nonresective'' therapy) of aortic aneurysms by d istal arterial ligation, coil/wire embolization, and extraanatomic byp ass was devalued by anecdotal reports emerging during the mid-1980s. N evertheless, we have recently found the technique to be life-saving in occasional cases and worth revisiting. Since 1990, standard aortic an eurysm repair has been performed in 231 patients (99.1% survival), end ovascular aortic aneurysm repair in 6 patients (83.3% survival), and c ombined surgical/interventional ''nonresective'' repair of a variety o f aneurysms in 10 patients (100% survival). Mean age of the group was 67.9 years. Repair was performed for aortoiliac aneurysms (4), common iliac aneurysms (3), internal iliac aneurysms (2), and a large proxima l subclavian artery pseudoaneurysm (1). Four of the patients had been explored and declared to be ''inoperable'' (retroperitoneal fibrosis) prior to transfer to the Columbia-Presbyterian Medical Center. All pat ients survived. Aneurysm rupture has not occurred in any patient, but one patient with a presumably thrombosed subclavian pseudoaneurysm pre sented 26 months postcoil-induced thrombosis with progressive aneurysm enlargement due to incomplete aneurysm thrombosis and required repair using circulatory arrest. Eight of the patients remain alive (80%) at a mean follow-up of 40.3 months (range 14-88 months). Two patients di ed of malignancy (30 months) and cardiac disease (15 months). It is co ncluded that combined surgical/interventional techniques can be life-s aving in the rare instances when conventional or endovascular aneurysm repair is not advisable but that complete aneurysm thrombosis is esse ntial and occasionally difficult to achieve. Since small proximal port ions of the aneurysm may remain patent and not be visualized on magnet ic resonance imaging (MRI) or computed tomography (CT) scans. contrast angiographic documentation of complete aneurysm thrombosis is essenti al prior to hospital discharge and close follow-up is necessary to asc ertain long-term adequacy of the repair. Incomplete thrombosis is susp ected as a major factor in earlier reports of aneurysm rupture after s eemingly successful nonresective therapy.