Ever since Dr. Gruentzig performed the first coronary balloon angioplasty in 1977, we have, as interventional specialists, begun to see our own types of complications. First, the phenomenon of intimal hyperplasia with restenosis was born after the introduction of balloon angioplasty. When Parodi first described a technique to less invasively exclude abdominal aortic aneurysms, we also developed our own unique type of endovascular complications. Potential endoluminal graft complications include dissection or perforation, device malfunction or failure, a thromboembolic event, prosthetic occlusion, prosthetic migration, prosthetic leak, limb ischemia, ischemic bowel, renal failure, wound infection, coagulopathy, and complications associated with treating patients with cardiovascular problems, including myocardial infarction, arrhythmia or death. In spite of this horrible hit parade of potential complications, endoluminal graft exclusion appears not only to be a viable alternative to open repair but quite frankly, patients really prefer this procedure. A recent article in the New England Journal of Medicine by the Dutch Randomized Endovascular Aneurysm and Management Group (DREAM), suggested that there was a reduction in severe complications with endovascular repair compared to open surgery.1 In spite of these great results with endoluminal exclusion, our unique problems continue with these patients. The authors describe 2 case reports of the use of endoluminal graft in patients with straightforward aneurysm. In both cases, the patients suffered asymptomatic periaortic inflammation following aneurysm repair for atherosclerotic abdominal aortic aneurysm. This complication is certainly rare, and in both cases, described that the authors treated the patients conservatively and signs of inflammation resolved with no further sequelae. Many people doing endovascular repair of abdominal aortic aneurysms have seen a nondescript inflammatory response in as many as 20% of patients. It is usually heralded by fatigue and fever without accompanying bacteremia or elevation of white blood cell count. In the past, we have pre-treated patients with anti-inflammatory agents such as indomethacin or in some cases, COX-2 inhibitors. This has reduced this phenomenon and in our experience, really never occurs when patients are pre-treated with anti-inflammatories. These case reports suggest that in 15 years of doing endoluminal exclusions, we have a lot more to learn and a lot more to study in terms of how patients react to these foreign products in their bodies. We will continue to have to be obsessed about ways to prevent complications and provide careful follow-up in patients undergoing this still fairly new type of therapy for arteriosclerosis.
richardheuser@phoenixheartcenter.com |
