Endovascular repair of aortic aneurysms: Critical events and adjunctive procedures

Objective: We sought to define the learning curve relative to the incidence and range of intraoperative problems and to establish guidelines for troub leshooting during the endovascular repair of infrarenal aortic aneurysms. Methods: We prospectively evaluated our first 75 consecutive cases over a 1 2-month period and focused on perioperative critical events and adjunctive procedures as categorical outcome measures collected during tile operation. Patients were separated into three groups on the basis of the date of thei r operation, such that group 1 consisted of our first 25 cases, group 2 our next 25 cases, and group 3 our last 25 cases. Results: At least one critical event and adjunctive procedure marked 67 (89 %) of 75 cases. In 51%, there were at least two critical events and adjunct ive procedures. There were no immediate open conversions or intraoperative deaths. Access problems occurred in 28% of the 75 cases and were addressed by use of brachial-femoral artery access (30%), iliac artery/aortic bifurca tion balloon angioplasty (8%), and iliofemoral conduits (4%). Craft foresho rtening was the most common deployment event (44%), necessitating distal co vered extensions. Iliac graft limb twists and kinks occurred in 12% of case s and were managed with balloon angioplasty and uncovered stents. General i ncidents included balloon ruptures (10%), arterial dissections (6%), iliac artery rupture (2.6%), and lower extremity ischemia (4%). The two cases of iliac artery rupture were managed with distal covered extensions, and there were no cases of atheroemboli. Intraoperative endoleaks were encountered i n 44% of the cases and included proximal attachment sites (15%), distal att achment sites (9%), type 2 sources, and "blushes." Management of intraopera tive endoleaks included proximal/distal covered extensions and re-balloonin g. Our 30-day endoleak rate was 20%. The incidence of critical events did n ot decrease in the latter one third compared with the first two thirds of c ases. Conclusions: Critical events occur frequently during endovascular repair of aortic aneurysms. The intraoperative problems range from the common endole aks, access and deployment issues, and balloon ruptures, to rare but life-t hreatening complications such as iliac artery rupture. A toolbox of accesso ries that includes wires, catheters, large balloons, covered proximal and d istal extensions, and uncovered stents is essential given the frequency of adjunctive procedures. Successful aortic endografting requires more than me re familiarity with basic endovascular techniques.