title: Endovascular repair of aortic aneurysms: critical events and adjunctive procedures.
abstract: OBJECTIVE
  We sought to define the learning curve relative to the incidence and range of intraoperative problems and to establish guidelines for troubleshooting during the endovascular repair of infrarenal aortic aneurysms.
  
  
  METHODS
  We prospectively evaluated our first 75 consecutive cases over a 12-month period and focused on perioperative critical events and adjunctive procedures as categorical outcome measures collected during the operation. Patients were separated into three groups on the basis of the date of their operation, such that group 1 consisted of our first 25 cases, group 2 our next 25 cases, and group 3 our last 25 cases.
  
  
  RESULTS
  At least one critical event and adjunctive procedure marked 67 (89%) of 75 cases. In 51%, there were at least two critical events and adjunctive procedures. There were no immediate open conversions or intraoperative deaths. Access problems occurred in 28% of the 75 cases and were addressed by use of brachial-femoral artery access (30%), iliac artery/aortic bifurcation balloon angioplasty (8%), and iliofemoral conduits (4%). Graft foreshortening was the most common deployment event (44%), necessitating distal covered extensions. Iliac graft limb twists and kinks occurred in 12% of cases and were managed with balloon angioplasty and uncovered stents. General incidents included balloon ruptures (10%), arterial dissections (6%), iliac artery rupture (2.6%), and lower extremity ischemia (4%). The two cases of iliac artery rupture were managed with distal covered extensions, and there were no cases of atheroemboli. Intraoperative endoleaks were encountered in 44% of the cases and included proximal attachment sites (15%), distal attachment sites (9%), type 2 sources, and "blushes." Management of intraoperative endoleaks included proximal/distal covered extensions and re-ballooning. Our 30-day endoleak rate was 20%. The incidence of critical events did not decrease in the latter one third compared with the first two thirds of cases.
  
  
  CONCLUSIONS
  Critical events occur frequently during endovascular repair of aortic aneurysms. The intraoperative problems range from the common endoleaks, access and deployment issues, and balloon ruptures, to rare but life-threatening complications such as iliac artery rupture. A toolbox of accessories that includes wires, catheters, large balloons, covered proximal and distal extensions, and uncovered stents is essential given the frequency of adjunctive procedures. Successful aortic endografting requires more than mere familiarity with basic endovascular techniques.
authors.affiliation: Division of Vascular Surgery at the University of Pennsylvania and Union Memorial Hospital, Philadelphia 19105, USA. rfairman@mail.med.upenn.edu
authors.forename: R M
authors.initials: RM
authors.lastname: Fairman
authors.forename: O
authors.initials: O
authors.lastname: Velazquez
authors.forename: R
authors.initials: R
authors.lastname: Baum
authors.forename: J
authors.initials: J
authors.lastname: Carpenter
authors.forename: M A
authors.initials: MA
authors.lastname: Golden
authors.forename: A
authors.initials: A
authors.lastname: Pyeron
authors.forename: F
authors.initials: F
authors.lastname: Criado
authors.forename: C
authors.initials: C
authors.lastname: Barker
mesh_terms: D001014:Aortic Aneurysm / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007431:Intraoperative Complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D008297:Male; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects* / Q000379:methods*