Incidence and treatment of intraoperative technical problems during endovascular repair of complex abdominal aortic aneurysms

Purpose: The purpose of this study was to assess the incidence and manageme nt of intraoperative technical problems during endovascular repair (EVR) of complex abdominal aortic aneurysms (AAA). Methods: From February 1995 to March 1999, 204 EVRs of nonruptured AAA were performed at our institution. One hundred seventy-six patients had an in-h ouse custom-made graft; 172 were aorto-uni-iliac grafts, and four were aort oaortic grafts. Twenty-eight patients had a bifurcated graft. One hundred f ourteen patients (56%) were high risk for conventional open repair. One hun dred nine patients (53%) were not suitable for most commercially available devices. Results: Intraoperative technical problems occurred in 81 patients (40%). T here were 37 endoleaks (27 proximal, 10 distal), 15 graft stenoses, one fai lure of graft deployment, two graft thromboses, three aortoiliac ruptures, five renal artery occlusions (one bilateral, four unilateral), and 18 inter nal iliac occlusions (five bilateral, 13 unilateral). Endovascular manageme nt of these problems was successful in 37 of the 81 patients (46%) and incl uded 15 balloon dilatations, 21 additional stent placements, and one graft thrombectomy. Fifteen of the 81 patients (19%) had open procedures (four pe riaortic ligature placements, six open aneurysm repairs, three common iliac ligations, and two extra-anatomic bypass grafts). In the remaining 29 pati ents, the on-table problem was managed expectantly. During follow-up, two o f 37 patients (5%) who were treated successfully with endovascular procedur es experienced recurrence. There were five deaths (33%) among the 15 patien ts who underwent open procedures. Conclusion: Intraoperative problems occur frequently during the endovascula r management of complex aneurysms. Many of these problems can be managed wi th additional endovascular techniques without an increased risk of recurren ce or procedure-related complications. Open procedures in high-risk patient s carry a high mortality rate. The team performing EVR of AAA should be ski llful in advanced endovascular and open surgical procedures.