What is a Ruptured Abdominal Aortic Aneurysm (AAA)?

Ruptured Abdominal Aortic Aneurysm (AAA) is the 13th leading cause of death in the United States. The routine management of AAA has been surgical bypass, with the placement of a graft in the involved segment. Although resection with synthetic grafting via transperitoneal or retroperitoneal approach has been the standard treatment, it is associated with significant risk. Complications include perioperative myocardial ischemia, renal failure, erectile impotence, intestinal ischemia, infection, lower limb ischemia, spinal cord injury with paralysis, aorto-enteric fistula, and death. Surgical treatment of AAA is associated with an overall mortality rate of 5% in asymptomatic patients, 16%-19% in symptomatic patients and is as high as 50% in patients with ruptured AAA. With the percutaneous placement of endoluminal stent grafts, major abdominal surgery and the related morbidity and mortality can potentially be avoided. This is particularly important because of the high incidence of co-existing morbid conditions such as cardiac, pulmonary and renal disease in these patients.

Over the past five years, there has been a great deal of research directed at developing less invasive, endovascular (catheter directed) techniques for the treatment of AAAs and iliac artery aneurysms. This has been facilitated by the development of vascular stents, which can and have been married to standard graft material in order to create a stent-graft or endograft. The potential advantages of less invasive treatments have included reduced surgical morbidity and mortality along with shorter hospital and ICU stays.

Stent-grafts or endoprostheses are now FDA approved and commercially available. The procedure involves advanced angiographic techniques performed through vascular accesses gained via surgical cutdown of a remote artery, which may include the common femoral or brachial arteries. The aneurysm will be crossed with a catheter and guide wire. Over the guide wire, the appropriate size introducer will be placed. Through the introducer, the stent-graft will be advanced to the appropriate position. Typical deployment of the stent-graft device requires withdrawal of an outer sheath while maintaining the position of the stent-graft with an inner-stabilizing device. Most stent-grafts are self-expanding; however, an additional angioplasty procedure may also be required to secure the position of the stent-graft. Following the placement of the stent-graft, standard angiographic views will be obtained.

Due to the large diameter (>20F) of these devices, arteriotomy closure will require open surgical repair. Some procedures may require additional surgical techniques, such as hypogastric artery re-implantation, vessel ligation, or surgical bypass, in order to adequately treat the aneurysm or to maintain flow to both lower extremities. Likewise, some procedures will require additional, advanced catheter directed techniques such as angioplasty, stent placement and embolization in order to successfully exclude the aneurysm and efficiently manage endoleaks.

For the foreseeable future, the need for both surgical and complex angiographic techniques will be required for the successful, cost effective placement of these devices. This approach is in keeping with many large centers that have been involved in the “pre-market approval” placement of these devices and will insure the safe delivery of this new technique to heath care systems and the community.