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For more than ten years now, the endovascular stentgrafting has become an alternative to the transabdominal surgery in regard to excluding infrarenal aneurysms. The methode has the advantage of a lower rate of perioperative morbidity and mortality in comparison to the open surgery. The method-associated need for reinterventions is a decisive disadvantage of the endoluminal stentgraft therapy.
Worldwide the minimal-invasive technique is being discussed quite controversially. This study is intented to present new results and aspects to this discussion. It is an evalution of the endoluminar stentgrafttherapy´s success, basing on the data of patients who had been studied at the University of Marburg.
The data of all patients being stentgrafted from the beginning of 1996 until the end of 2002 has been included in this study. The follow-up ended in October 2003. All 39 patients suffered from an infrarenal aortic aneurysm which was either sized at least 50mm or was symptomatic. All patients were unfit for open transabdominal surgery. 53,5% of the patients belonged to the ASA-class III, the other 46,5% belonged to the ASA-class IV.
The perioperative (30 days-) mortalityrate was 0%. In regard to stentgraft- or aneurysm associated deaths, the longtime-mortalityrate was 0% also. Five patients died of cardial reasons during the follow-up period. Furthermore there were no rupture aneurysms during the follow-up. In 46,2% of patients we noticed endoleaks. The rate of primary endoleaks was 36%, the rate of secondary endoleaks was 10,3%. Taking all patients into consideration, 20,5% had a type IA endoleak, 7,7% had a type IB endoleak, 12,8% had a type II endoleak, 2,6% had a type III endoleak and 2,6% had an Type I endoleak as well as a type II endoleak. Further complications during the follow-up were noticed as well; those were migrations in 10,3% and graftstenosis in 7,7% of cases.
The overall interventionrate was 48,7%, which also includes the explantationrate: a conversion to a transabdominal surgery has been proceeded in 7,7%. Furthermore we found embolisations in 17,9% and dilatations in 10,3% of all cases. 10,3% of patients underwent a proximal stentgraft extension and 10,3% a distal stentgraft extension. In 7,7% there was implanted a second stent (with open design), 2,6% received a second complete stentgraft inside the first one and 2,6% got an secondary crossover bypass.
In most cases the aneurysm size stagnated or shrinked, which is a marker for the therapy´s success. The portions of the average aneurysmdiameter changed during the follow-up period: Twelve months after implantation we realized a shrinkagerate of 29,6% and a growthrate of 3,5% of aneurysms. After 24 months, 39,1% of aneurysmdiameters has decreased and 8,7% increased while after 48 months even 50% were shrinked and 21,4% were grown. Finally we concluded that the aneurysmgrowth correlates with the presence of endoleaks.
The often described advantage of the endovascular therapy of having a low mortalityrate has been confirmed in our study as well .The high rate of reintervetions however is an unsolved problem. The technique´s major problem is the lacking proximal stentgraft adaptation. The consequences are Typ IA leakages and migrations.
The indication of this therapy should be evaluated individually and only in case of highrisk patients. In regard to high complication rates, the endovascular therapy offers no complete replacement for the common open abdominal surgey, while it is the better alternative in regard to highrisk patients.