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+++++++++++++++++++++++++++++++++++++++++ + +++ +CARDioVASCuLAR SPECiAL SECTioN ��� +++ +++++++++++++++++++++++++++++++++++++++++ Endovascular Repair of Abdominal Aortic Aneurysm by brett butler, mD A BDoMinal aortic aneUrYSM (AAA) occurs in 5% to 7% of the population over the age of 60. There is no known cause, but risk factors may include hypertension, high cholesterol, smoking, obesity and genetic predisposition. Statistics show that men are more often affected by AAA than women. By definition, an aneurysm is any vessel that shows a 50% enlargement in diameter. Because the vast majority are asymptomatic, aneurysms ��� which grow about 2-4 mm per year ��� usually grow undetected. AAA is often discovered, however, by a primary care physician who finds a pulsatile abdominal mass during a routine physical examination, or a radiologist who discovers an enlarged blood vessel in an X-ray or CT scan prescribed for an unrelated health issue. Patients who are symptomatic ��� with severe abdominal or back pain, sometimes accompanied by a drop in blood pressure ��� must be treated urgently. Ruptured AAA has an 80% mortality. To avoid rupture, aneurysms are typically repaired when they reach 5 to 5-1/2 cm in diameter. Historically, this entailed a large abdominal incision with sewn-in graft material from above the aneurysm to distal normal arteries. In the early 1990s, Juan C. Parodi, MD, completely revolutionized the treatment of aneurysms when he performed the first endovascular AAA repair. Using graft material sewn onto stents, he deployed them through the arteries in the groin. By the late 1990s, several companies developed different designs using different graft materials and different metals for the stents to create what we now call stent grafts. As a result, endovascular aneurysm repair can now be performed percutaneously through two very small groin incisions. The main advantages, when compared to open abdominal repair, are less perioperative mortality (with open repair, it is 5%); shorter hospital stay (one to two days, as compared to five to seven days); earlier return to normal lifestyle (two weeks instead of three months); and fewer wound complications. The disadvantage to the patient is more frequent follow-up 16 | Cleveland/Akron/Canton MD News ��� MDneWS.coM ��� MarcH -april 2013 visits, which include annual ultrasound or CT scans to ensure the stent remains intact and the aneurysm continues to shrink around the stent graft. Presented below is a case study of a patient with AAA complicated by aortic iliac occlusive disease, which caused thrombosis of the aneurysm. He was successfully treated with thrombolysis followed by endovascular aortic aneurysm repair. case Study A 59-year-old male in a wheelchair was brought to the Emergency Department with three-day ischemia to both legs. On questioning, he described worsening bilateral leg claudication over the past year. A physical examination revealed faint signals in both groins, excoriation on buttocks and groins and ischemic feet. The patient complained of pain in his buttocks and legs, which was determined to be from lack of blood flow. He was obese and a three-pack per-day smoker, and reported comorbidities of HTN, COPD and DM. A CT scan showed a 5 cm thrombosed abdominal aortic aneurysm with thrombus extending down the right external iliac artery. This also showed severe calcific disease of bilateral common iliac arteries. The common femorals and superficial femorals had minimal disease. To dissolve the blood clots rapidly, catheters were placed percutaneously through the groin and left arm to the targeted sites to deliver thrombolytic drugs directly to the clots via EKOS (an ultrasound accelerated infusion system). After two days, the clots were dissolved and blood flow was restored to the patient���s buttocks and legs. This relieved his pain. Two days later, an endovascular aneurysm was performed. The patient was discharged to a rehabilitation facility, because of his other comorbidities, two days later. At four months follow-up, the aneurysm was excluded and improved circulation with palpable right pedal pulses and left pedal signals. The patient is now walking again. Brett Butler, MD, is a board-certified vascular surgeon. He���s a member of the physician staff at Aultman Hospital. ���