[Abstract] OBJECTIVE: To investigate the choice of surgical and endoluminal treatment strategies for peripheral aneurysms. METHODS: A retrospective analysis of 35 cases of peripheral aneurysm admitted and operated from July 1998 to December 2007. Among them, 11 cases of N aneurysm, 15 cases of femoral aneurysm, 4 cases of carotid aneurysm, and 5 cases of subclavian aneurysm were treated by surgical open surgery or endoluminal repair. Results: There were 24 cases of open surgery, 23 cases of reconstructed arteries, 15 cases of artificial vessels for vascular grafts, and 8 cases of autologous saphenous vein; 11 cases of endoluminal treatment were performed, including 10 cases of stent vessels. The 5-year cumulative patency rate of surgical reconstructive vascular grafts was 68%, and the 5-year cumulative patency rate of stent vessels was 52%, and 2 cases died of cardiovascular disease during the follow-up period. Conclusion: For most peripheral aneurysms, surgical open surgery can achieve satisfactory clinical results. However, for aneurysms with deep locations or difficult surgical dissection, endoluminal treatment techniques can be an important supplement to open surgical procedures to reduce surgical trauma and complication rates.
[Keywords] Aneurysm; surgical treatment; stent
Treatment strategies of peripheral arterial aneurysms
JIA Xin, GUO Wei, LIU Xiao-ping, YIN Tai, XIONG Jiang, ZHANG Hong-peng, ZHANG Guo-hua, LIANG Fa-qi Department of Vascular Surgery, PLA General Hospital Beijing 100853, China
Corresponding author: GUO Wei Email:[email protected]
[Abstract] Objective: To investigate the treatment strategies of peripheral arterial aneurysms. Methods: 35 cases were reviewed from July 1998 to December 2007, 11 cases were popliteal artery aneurysms, 15 cases were femoral artery aneurysms, 4 cases were extracranial carotid aneurysms and 5 cases were subclavian artery aneurysms. All cases had either surgical procedures or endovascular procedures. Results: Surgical procedures were performed on 24 cases, 15 revascularized artery aneurysms, and 3 revascularized artery aneurysms. All cases had either surgical procedures or endovascular procedures. The accumulative five year patency were 68% and 52% for surgical grafts and stentgrafts respectively. Conclusion: Surgical procedure is suitable for most The surgical procedure is suitable for most peripheral arterial aneurysms and endovascular repair has its own advantage for those complicated cases with difficult anatomy.
[Key words】 aneurysm; surgical procedure; stents
Peripheral aneurysms are aneurysms that occur in the arteries of the extremities, including the carotid artery, bilateral upper and lower extremity arteries. Compared with the thoracoabdominal aorta, the incidence of true aneurysms of the peripheral arteries is much lower, and thus the literature on related diagnostic and treatment experiences is not very common [1-6]. In this paper, we retrospectively analyzed 35 patients with peripheral aneurysms admitted and operated at our center from July 1998 to December 2007, hoping to provide a little reference for the diagnosis and treatment of these diseases.
1. Data and methods
1.1 General information
There were 35 cases in this group, 28 males and 7 females, with an average age of 56.3±13.5 (25-81) years. According to the site of onset, there were 11 cases of N aneurysm, of which 3 were bilateral, 15 cases of femoral aneurysm, of which 2 were bilateral, 4 cases of carotid aneurysm, and 5 cases of subclavian aneurysm. Concomitant diseases included hypertension in 20 cases, coronary heart disease in 14 cases, old myocardial infarction in 5 cases, cerebral infarction in 6 cases, chronic obstructive pulmonary disease in 6 cases, leukoaraiosis in 3 cases, Marfan syndrome in 2 cases, polyarteritis nodosa in 1 case, and combined abdominal aortic aneurysm in 7 cases.
1.2 Methods
1.2.1 Preoperative evaluation.
All cases were clearly diagnosed by imaging (vascular ultrasound, CTA or MRA) to assess the extent of aneurysmal lesion involvement and inflow and outflow tract vessels to guide the selection of surgical plan; for patients with carotid aneurysm and subclavian aneurysm, preoperative carotid or vertebral artery selective angiography was performed to assess whole brain perfusion, and Matas test was performed to understand Willis loop traffic.
1.2.2 Surgical plan development
Eleven cases of N aneurysm were performed, and all of them were operated by surgical open surgery. The N artery was reconstructed by surgical bypass after ligation at both ends of the N artery aneurysm. 8 cases were treated with an autologous ipsilateral saphenous vein, and 3 cases were treated with a 6-mm diameter PTFE (GORETEX) artificial vessel. The proximal anastomosis was at the proximal end of the N aneurysm, the distal anastomosis was at the distal N artery of the aneurysm in 4 cases, and the anastomosis was at the tibiofibular trunk artery in 7 cases.
In 15 cases of femoral aneurysm, 8 cases were operated surgically with aneurysm resection and reconstruction of the femoral artery with artificial vessels. The position was lying, a straight inguinal incision was made, and the common femoral and superficial and deep femoral arteries were freed. In five cases, the aneurysm involved the deep femoral artery, and reconstruction of the deep femoral artery was performed at the same time. 7 cases were treated with endoluminal therapy, three of which were located in the deep femoral artery and four in the superficial femoral artery. Depending on the diameter of the involved vessels, WALLGRAFT TM (BOSTON SCIENTIFIC) stent vessels or JOMED TM (ABBOTT) stent vessels were used. The former had a diameter of 6 mm to 8 mm and a length between 3 cm and 5 cm; the latter had a diameter of 3 mm to 4 mm and a length of 2 cm.
In the other case, because the location of the aneurysm reached as high as the base of the skull, it was difficult to reconstruct the internal carotid artery, so the distal internal carotid artery was directly ligated after resection of the aneurysm without reconstruction. In the other two cases, one case was treated with WALLGRAFT TM (BOSTON SCIENTIFIC) stent vessel with a diameter of 8 mm and a length of 5 cm, and the other case was evaluated with good cerebral circulation compensation and the aneurysm was closed by embolization of the affected internal carotid artery with a spring coil.
In the other two cases, the aneurysms were located in the distal and proximal axillary arteries of the subclavian artery, and the subclavian aneurysm and axillary aneurysm were resected by using a parallel incision below the supraclavicular level, respectively. In the other two cases, the aneurysms were located in the distal subclavian artery and the proximal axillary artery, and the subclavian aneurysm and axillary aneurysm were resected using a parallel incision below the supraclavicular bone, and then the arteries were reconstructed with artificial vessels.
1.2.3 Follow up.
Follow-up visits were performed at 6 months, 12 months and annually thereafter, by means of vascular ultrasound, CTA and MRA, to observe changes in the aneurysm, as well as to understand whether there were any systemic comorbidities or complications and whether limb ischemia had occurred. Vascular graft patency, stent vessel patency, morphology and endoleaks were recorded, and Kaptan-Meier survival curve analysis was applied to estimate various graft patency rates.
2. Results
2.1 Perioperative outcomes.
In this group of 35 patients, there were 24 cases of surgical open surgery, 23 cases of surgical artery reconstruction, and 1 case of carotid aneurysm resection without reconstruction; 15 cases of artificial vessels and 8 cases of autologous saphenous vein were selected for vascular grafts; 11 cases of endoluminal treatment were performed, of which 10 cases applied stent vessels (7 cases of WALLGRAFT and 3 cases of JOMED) and 1 case of carotid aneurysm directly performed aneurysm embolization. There was one acute heart attack and one stroke within 7 days after surgery, and no perioperative death; all stent vessels were successfully released with accurate positioning, no type I endoleaks, and no perioperative death or serious complications in the endoluminal treatment cases.
2.2 Follow-up results.
Thirty-one cases in this group were followed up postoperatively and 4 cases were lost, with a follow-up rate of 87% and a follow-up period of 7 months to 6 years, with an average of 41 months. No tumor rupture-related death occurred in the whole group, and no postoperative tumor thrombosis or cessation of growth occurred in the endoluminal repair cases, and no stent displacement or late type I endoleaks occurred. The 5-year cumulative patency rate of surgical revascularization grafts was 68%, and the 5-year cumulative patency rate of stented vessels was 52%. 1 patient with N aneurysm had a sudden massive cerebral infarction and left hemiparesis in 7 months after surgery, 1 patient with subclavian aneurysm had a sudden cerebral hemorrhage and died in 14 months after surgery, and 1 patient with femoral aneurysm had an acute myocardial infarction and died in 32 months after surgery.
3. Discussion
Peripheral aneurysm is a rare disease, and there is a lack of reports in the domestic and international literature. For most peripheral aneurysms, surgical open surgery can achieve satisfactory medium- and long-term clinical results. However, for aneurysms with deep location or difficult surgical dissection, surgery is more traumatic, and surgical complications are high because patients are mostly of advanced age [1-7]. In recent years, the emergence of endoluminal treatment techniques has become an important supplement to open surgical procedures, which can reduce surgical trauma and complication rates and expand the indications for surgery [8].
3.1 Lower extremity aneurysm treatment strategy selection.
N aneurysms are superficially located, and the surgical operation is relatively easy and less traumatic. All 11 cases in this group were operated by surgical bypass, with ligation of both ends of the aneurysm and reconstruction of the N artery. 8 cases were operated by autologous saphenous vein bypass, 3 cases were operated by artificial vessels because the autologous vein was not available, and 1 case had an acute cerebral infarction 3 days after the operation and was left with hemiparesis. The autologous saphenous vein and the artificial vascular graft were each occluded in 2 cases within 5 years, with patency rates of 72% (5/7, 1 lost to follow-up) and 33% (1/3), respectively. Thus, autologous saphenous vein grafts were significantly superior to artificial vessels. Since most N aneurysm lesions span the knee joint, the current stent vessels are stiff in texture, and therefore current endoluminal treatment is not appropriate in this site [8].
Most femoral aneurysms occur in the common femoral artery and often involve the bifurcation of the superficial and deep femoral arteries, which are also more easily exposed and suitable for surgical procedures, and if the lesion involves the deep femoral artery, reconstruction of the deep femoral artery is required. In our group, eight cases of femoral aneurysm underwent open surgery, and all of them used artificial vessels to reconstruct the artery. One case had an acute heart attack after surgery, which improved after drug treatment. The five-year patency rate of postoperative vascular grafts was 72% (5/7, 1 lost). 7 cases were superficial and deep femoral artery aneurysms with relatively deep anatomical sites, and 4 cases were combined with vascular inflammation, which made the surgery more difficult, so endoluminal treatment was used to reduce surgical trauma and possible complications. Depending on the vessel diameter, WALLGRAFT TM (BOSTON SCIENTIFIC) or JOMED TM (ABBOTT) stent vessels were applied. There were no serious perioperative complications in patients treated endoluminally, but the patency rate was 57% (4/7) at the five-year postoperative follow-up, which was inferior to open surgery cases, suggesting that the current stent vessels need further improvement and refinement.
3.2 Choice of treatment strategy for head and arm aneurysms.
Most carotid aneurysms are located near the bifurcation of the carotid artery, which is a relatively superficial anatomy and suitable for open surgical procedures. However, if the location of the aneurysm is too high near the skull base or too low into the thoracic cavity, it will increase the difficulty of surgery, at this time, intracavitary treatment can give full play to the advantages of minimally invasive. In our group, two cases were operated, one of which had a tumor located as high as the skull base, so part of the mandible was sawed off to facilitate the operation due to the difficulty of exposure. In the other case, the location of the aneurysm was as high as the skull base, which was difficult to expose, and the contralateral cerebral circulation was fully evaluated to be well compensated.
The location of subclavian artery aneurysm is relatively deep, especially the proximal subclavian artery is located behind the sternum, so most of the surgical procedures need to open the chest in order to expose the aneurysm, at this time, the intracavitary treatment can play its minimally invasive advantage. In this group, three surgical procedures were performed, one case was open to reconstruct the artery, two cases were located in the distal subclavian artery and proximal axillary artery, and the artery was reconstructed after direct excision of the aneurysm. two cases were endoluminal repairs, one case was located in the right subclavian artery far from the vertebral artery, and endoluminal repair was performed with WALLGRAFT TM (BOSTON SCIENTIFIC) stent vessel to preserve the vertebral artery; the other case was located in the right subclavian artery. In the other case, the aneurysm was located in the proximal right subclavian artery, the distal vertebral artery was occluded, and there was no sufficient anchorage area in the proximal end. The WALLGRAFT TM (BOSTON SCIENTIFIC) stent vessel was released from the nameless trunk and reached the right common carotid artery distally, isolating the right subclavian artery and the aneurysm together. The five-year patency rates of open surgery and endoluminal treatment of the vascular grafts were 67% (2/3) and 50% (1/2, 1 lost case), respectively.