Endovascular grafts and other image-guided catheter-based adjuncts to improve the treatment of ruptured aortoiliac aneurysms

Objective To report a new management approach for the treatment of ruptured aortoiliac aneurysms. Methods This approach includes hypotensive hemostasis, minimizing fluid res uscitation, and allowing the systolic blood pressure to fall to 50 mmHg. Un der local anesthesia, a transbrachial guidewire was placed under fluoroscop ic control in the supraceliac aorta. A 40-mm balloon catheter was inserted over this guidewire and inflated only if the blood pressure was less than 5 0 mmHg, before or after the induction of anesthesia. Fluoroscopic angiograp hy was used to determine the suitability for endovascular graft repair. Whe n possible, a prepared, "one-size-fits-most" endovascular aortounifemoral s tented PTFE graft was used, combined with occlusion of the contralateral co mmon iliac artery and femorofemoral bypass. If the patient's anatomy was un suitable for endovascular graft repair, standard open repair was performed using proximal balloon control as needed. Results Twenty-five patients with ruptured aortoiliac aneurysms (18 aortic, 7 iliac) were managed using this approach. Balloon inflation for proximal control was required in nine of the 25 patients. Twenty patients were treat ed with endovascular grafts. Five patients required open repair. The ruptur ed aneurysm was excluded in all 25 patients; 23 survived. Two deaths occurr ed in patients who received endovascular grafts with serious comorbidities. The surviving patients who received endovascular grafts had a median hospi tal stay of 6 days, and the preoperative symptoms resolved in all patients. Conclusions Hypotensive hemostasis is usually an effective means to provide time for balloon placement and often for endovascular graft insertion. Wit h appropriate preparation and planning, many if not most patients with rupt ured aneurysms can be treated by endovascular grafts. Proximal balloon cont rol is not required often but may, when needed, be an invaluable adjunct to both endovascular graft and open repairs. The use of endovascular grafts a nd this approach using other image-guided catheter-based adjuncts appear to improve treatment outcomes for patients with ruptured aortoiliac aneurysms .