**6. Operative data and results (Nürnberg experience and Army's Clinic Center for Cardiovascular Diseases, Bucharest)**

We have conducted a prospective, randomized study starting from 1994, including patients diagnosed with infrarenal aortic aneurysm with a diameter ≥ 5.5 cm. The purpose of this study was to assess the results of abdominal aortic aneurysm repair of two large volume centers, in terms of perioperative, early and midterm complications, reintervention rate and mortality.

*Exclusion criteria were*: Presence of comorbidities that could affect the postoperative surveillance: Renal insufficiency with serum creatinine level > 1.5 mg/dl, serum urea > 50 mg/dl, mental illnesses, hypersensitivity to the contrast agent, unable to be followed as an outpatient, claustrophobia, the presence of previously implanted metal devices: pace makers, mechanical heart valves etc.

*Collected data:* The collected data was entered in an excel database. Patient demographics and other variables were introduced, like:


In Nürnberg, we started endovascular treatment in 1994 with Ancure stent-graft. In our 14– years experience of 1502 cases (ending dec. 2007) we have used 13 different endografts. From them, 1391 were men and 111 women, with a mean age of 71.5 years (41-98). The median follow up was 41 months (1.0-98) and the AAA had a mean diameter of 52.4 cm. For short and angulated necks we prefer now the Powerlink (Irvine, CA, USA) device, which we have started in 1999 [72]. Ending Dec. 2007, 519 cases were done using Powerlink grafts.

184 Aneurysm

mortality.

**Figure 10.** Schema of modular endograft deployment

makers, mechanical heart valves etc.

and other variables were introduced, like:

**Center for Cardiovascular Diseases, Bucharest)** 

occurred (endoleak, endograft migration, kinking)

**6. Operative data and results (Nürnberg experience and Army's Clinic** 

We have conducted a prospective, randomized study starting from 1994, including patients diagnosed with infrarenal aortic aneurysm with a diameter ≥ 5.5 cm. The purpose of this study was to assess the results of abdominal aortic aneurysm repair of two large volume centers, in terms of perioperative, early and midterm complications, reintervention rate and

*Exclusion criteria were*: Presence of comorbidities that could affect the postoperative surveillance: Renal insufficiency with serum creatinine level > 1.5 mg/dl, serum urea > 50 mg/dl, mental illnesses, hypersensitivity to the contrast agent, unable to be followed as an outpatient, claustrophobia, the presence of previously implanted metal devices: pace

*Collected data:* The collected data was entered in an excel database. Patient demographics

 Qualitative variables: endovascular treatment indication, name and type of prosthesis used, vascular access method (percutaneous puncture of the femoral artery, surgical incision, temporary iliac conduit), type of anaesthesia, postoperative complications

 Continuous quantitative variables: pre- and postoperative data on aneurysm morphology determined by CTA preoperatively and by DUS and CTA postoperatively (maximal anterior-posterior and transverse dimension of the aneurysm sac, length of the aneurysm, size and morphological changes of the aneurysm neck, the distance between the aneurysm and the emergence of the renal arteries, common iliac artery length and

In Nürnberg, we started endovascular treatment in 1994 with Ancure stent-graft. In our 14– years experience of 1502 cases (ending dec. 2007) we have used 13 different endografts.

diameter) duration of intervention, the amount of blood loss, reinterventions.

The 30 day mortality was 1.7%. The total reintervention rate was 5.3%, while no distal migration, conversion or post Evar rupture occurred. Using this device we arrive to treat endovascularly 85-90% of the infrarenal AAAs in our hospital.

At the **Army's Clinic Center for Cardiovascular Diseases,** Bucharest, between July 2008 - December 2010, 17 patients underwent EVAR for Abdominal Aortic Aneurysm (AAA), with age range between 49-82 years and aneurysm mean diameter 7.1 ± 0,5 cm (range: 5.4 – 8.2 cm) [73].

The preoperative assessment was achieved using Doppler Ultrasound (DUS), Multislice CT, and sometimes DSA (Digital Substraction Angiography). The measurements for the graft type and dimensions were done according to the Multislice CT analyzing. (**Figure 11 a, b and c**).

**Figure 11. a), b)** Preoperative multislice CT of a infrarenal AAA, with a suitable anatomy (2.2 cm neck length, no involvement of iliac arteries, 5.3 cm transversal diameter**. c)** Preoperative substraction angiography – with a catheter measuring the real length of the Aorta

The EVAR devices used for these patients were:


The access was bifemoral, through open femoral incision, with peridural anaesthesia.

Until present they followed our institutions surveillance protocol, that consisted of both DUS and CTA examination at 1,3,6,12 months and yearly after EVAR. None of them went through all of the surveillance dates (due to high examination costs) but each has at least 3 sets of examinations, one set consisting of both DUS and CTA.

The technical success rate was 100%, with no perioperative and postoperative complications regarding endoleaks, graft migration and graft component failure. 4 patients had access site complications, 3 had groin haematomas that reabsorbed after approximately 1 week and 1 returned with an infection at the level of the inguinal incision, which resolved also with wound care. There were no conversions to open repair up to present. The stent-graft patency rate at this point at these patients is 100%.

**Figures 12** and **13** show two cases of AAAs treated with two different devices and two different strategies: Anaconda (Terumo) device and Powerlink (Endologix) stent graft.

**Figure 12.** AAA treated with Powerlink Endograft **a)** Proximal extension; **b)** Main body of the stentgraft; **c)** The two iliac segments of Powerlink® system

**Figure 13. a)** Anaconda endograft for infrarenal abdominal aortic aneurysm therapy; **b)** Angiography at the beginning of the procedure; **c)** The main body of the stent; **d)** The two iliac Anaconda system
