Endoluminal stent grafts in the management of infrarenal abdominal aortic aneurysms: a realistic assessment

Objectives: transfemoral endoluminal aortic management (TEAM) is technicall y feasible in the treatment of infrarenal abdominal aortic aneurysms but it s advantage over conventional repair is unproved. We report our initial exp erience, learning curve and technical difficulties encountered during the p rocess of establishing this novel technique in our institute. Material and Methods: over a 3-year period 400 cases of abdominal aortic an eurysms were reviewed; only 58 cases (15%) were suitable for endovascular r epair under our TEAM protocol and 36 (9%) were offered endovascular interve ntion. They were mainly high-risk patients (85% ASA III and IV) with a mean age of 72 years. Thirty-three bifurcated grafts, two straight tube grafts and one aorto mono-iliac graft were deployed. We oversized the grafts by 15 -20% to the diameter of the aortic neck and both common iliac arteries. Results: two cases (6%-95% CI: 1-19%) had on-table conversion because of ru ptured common iliac arteries. Perioperatively there were two deaths from mu lti-organ failure. Transient renal failure occurred in two patients and thr ee patients (9%) suffered a non-fatal myocardial infarction. Sixteen percen t of patients had a groin wound problem. The mean hospital stay was 7 days. Five minor endoleaks (15%) were identified and sealed at 30 days. One seco ndary endoleak was identified at 18 months because of a patent juxta-renal lumbar artery. No secondary cuffs or extensions were used. Mean follow-up w as 29 months and all grafts remained patent. The technical, clinical, conti nuous and secondary success rates were 78%, 91%, 89% and 91% respectively w ith TEAM. Conclusion: endovascular training, patient selection and learning curve imp ose an impact on the final outcome. Until a reliable hard point is reached so that endovascular repair could be exercised in routine practice, the use of TEAM must be questioned in high-risk patients, and should be performed under clinical trial conditions using strict selection criteria.