Endovascular stent-graft (ESG) repair of abdominal aortic aneurysm (AAA) has emerged as an alternative to open surgery. The role of ESG in patients with challenging medical and anatomic problems remains an area of general debate. This study reviews an experience with stent grafts to treat patients with AAA and atheromatous embolization syndrome (AES) presenting with chronic distal embolization (CDE).Over a 5-year period 660 patients with AAA were treated with aortic stent grafts. Patients with AAA and ischemic ulcerations or toe gangrene due to CDE despite palpable foot pulses were investigated for successful aneurysm exclusion, resolution of ischemic symptoms, complications and survival. Follow-up averaged 15.3 +/- 14.9 months (range, 1 to 60 months).Nineteen patients had AAA and manifestations of CDE. The population (16 males/3 females) had a mean age of 79 +/- 7 years and mean aneurysm diameter of 5.5 cm. Renal insufficiency was present in 5/19 (26 %). Ischemia presented as ischemic ulcers (16/19 [84.2%]) or toe gangrene (3/19 [15.8%]). Stent grafts included 6 aortouniiliac and 13 bifurcated devices. Exclusion was achieved in all but 2 patients who had type II lumbar endoleaks. At 30-day postoperative follow-up, mortality was 0 % and resolution of CDE/ischemia was noted in 2 of 19 (10.5%) patients. Eight of 9 patients with follow-up of 1 year had complete resolution of their ischemic symptoms, with no recurrent manifestations of AES. Complications included progression of renal insufficiency over an 18-month period in 1 patient and an unstable expanding pararenal aortic neck in 1 patient. Foot ischemia persisted at 1 year in a patient with severe coexisting thoracic aortic disease despite successful AAA exclusion. Six (31.6%) patients died during a mean follow-up of 15.3 months from causes unrelated to their AAA.On the basis of this experience, stent-graft repair of AAA and CDE may be an effective strategy to prevent future embolization. Recognition of coexisting thoracic aortic disease is essential. ESG does not address the extremely high morbidity and mortality from cardiovascular causes in this population.

Over the last decade, more than 25,000 endovascular stent grafts have been used to treat aortic aneurysms. Although results have been promising thus far, problems with endoleaks, material failure, device migration, and aneurysm rupture continue to be reported. Improvements in device material and design have contributed to the rapid growth and utility of these devices; however, material failure still remains a concerning mode for potential procedure failure. A review of the authors’experience with material failure and a review of the literature was conducted to help understand and comprehend the magnitude of this problem and try to determine its clinical significance.

OBJECTIVES:Endovascular stent-graft repair has great potential in treatment of thoracic aortic aneurysms. This study analyzed a single center's experience with first-generation commercially produced thoracic stent grafts used to treat descending thoracic aortic aneurysms.METHODS:Over 58 months 84 patients underwent endovascular stent-graft repair of descending thoracic aortic aneurysms; 22 patients received the Gore TAG stent graft, and 62 patients received the Talent thoracic endovascular stent-graft system. Each patient was enrolled in one of three distinct US Food and Drug Administration trials at Mount Sinai Medical Center in accordance with strict inclusion and exclusion criteria, including suitability for open surgery, aneurysm anatomy, and presence of comorbid medical illness. Mean age of this cohort was 71 +/- 12 years. There were 54 men and 30 women, and 74 (88%) had three or more comorbid illnesses. Primary technical success was achieved in 76 patients (90%). Mean follow-up was 15 months (range, 0-52 months).RESULTS:Successful aneurysm exclusion was achieved in 69 patients (82%). Major procedure-related or device-related complications occurred in 32 patients (38%). There were six proximal attachment failures (8%), four distal attachment failures (6%), one intergraft failure (1%), two mechanical device failures (3%), five periprocedural deaths (6%), and five late aneurysm ruptures (6%). At 40 months, overall survival was 67% (+/-10%), and freedom from rupture or from type I or type III endoleak was 74% (+/-10%).CONCLUSION:While promising, this midterm experience with commercially available devices highlights the shortcomings of current stent-graft technology. Three significant advancements are required to fulfill the potential of this important treatment method: a stent graft with a durable proximal and distal fixation device, enhanced engineering to accommodate high thoracic aortic fatigue forces, and a mechanism to adapt to aortic arch and visceral segment branches to enable treatment of lesions that extend to or include these vessels.

Objective: On November 23, 1992, the first endovascular stent graft (ESG) repair of an aortic aneurysm was performed in North America. Following the treatment of this patient, we have continued to evaluate ESG over the past 10 years in the treatment of 817 patients. Summary and Background Data: Abdominal (AAA) or thoracic (TAA) aortic aneurysms are a significant health concern traditionally treated by open surgical repair. ESG therapy may offer protection from aneurysm rupture with a reduction in procedure morbidity and mortality. Methods: Over a 10-year period, 817 patients were treated with ESGs for AAA (723) or TAA (94). Patients received 1 of 12 different stent graft devices. Technical and clinical success of ESGs was reviewed, and the incidence of procedure-related complications was analyzed. Results: The mean age was 74.3 years (range, 25–95 years); 678 patients (83%) were men; 86% had 2 or more comorbid medical illnesses, 67% of which included coronary artery disease. Technical success, on an intent-to-treat basis was achieved in 93.8% of patients. Primary clinical success, which included freedom from aneurysm-related death, type I or III endoleak, graft infection or thrombosis, rupture, or conversion to open repair was 65 ± 6% at 8 years. Of great importance, freedom from aneurysm rupture after ESG insertion was 98 ± 1% at 9 years. There was a 2.3% incidence of perioperative mortality. One hundred seventy five patients died of causes not related to their aneurysm during a mean follow-up of 15.4 months. Conclusions: Stent graft therapy for aortic aneurysms is a valuable alternative to open aortic repair, especially in older sicker patients with large aneurysms. Continued device improvements coupled with an enhanced understanding of the important role of aortic pathology in determining therapeutic success will eventually permit ESGs to be a more durable treatment of aortic aneurysms.