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1.  Endovascular Repair of Descending Thoracic Aortic Aneurysm 
Executive Summary
Objective
To conduct an assessment on endovascular repair of descending thoracic aortic aneurysm (TAA).
Clinical Need
Aneurysm is the most common condition of the thoracic aorta requiring surgery. Aortic aneurysm is defined as a localized dilatation of the aorta. Most aneurysms of the thoracic aorta are asymptomatic and incidentally discovered. However, TAA tends to enlarge progressively and compress surrounding structures causing symptoms such as chest or back pain, dysphagia (difficulty swallowing), dyspnea (shortness of breath), cough, stridor (a harsh, high-pitched breath sound), and hoarseness. Significant aortic regurgitation causes symptoms of congestive heart failure. Embolization of the thrombus to the distal arterial circulation may occur and cause related symptoms. The aneurysm may eventually rupture and create a life-threatening condition.
The overall incidence rate of TAA is about 10 per 100,000 person-years. The descending aorta is involved in about 30% to 40% of these cases.
The prognosis of large untreated TAAs is poor, with a 3-year survival rate as low as 25%. Intervention is strongly recommended for any symptomatic TAA or any TAA that exceeds twice the diameter of a normal aorta or is 6 cm or larger. Open surgical treatment of TAA involves left thoracotomy and aortic graft replacement. Surgical treatment has been found to improve survival when compared with medical therapy. However, despite dramatic advances in surgical techniques for performing such complex operations, operative mortality from centres of excellence are between 8% and 20% for elective cases, and up to 50% in patients requiring emergency operations. In addition, survivors of open surgical repair of TAAs may suffer from severe complications. Postoperative or postprocedural complications of descending TAA repair include paraplegia, myocardial infarction, stroke, respiratory failure, renal failure, and intestinal ischemia.
The Technology
Endovascular aortic aneurysm repair (EVAR) using a stent graft, a procedure called endovascular stent-graft (ESG) placement, is a new alternative to the traditional surgical approach. It is less invasive, and initial results from several studies suggest that it may reduce mortality and morbidity associated with the repair of descending TAAs.
The goal in endovascular repair is to exclude the aneurysm from the systemic circulation and prevent it from rupturing, which is life-threatening. The endovascular placement of a stent graft eliminates the systemic pressure acting on the weakened wall of the aneurysm that may lead to the rupture. However, ESG placement has some specific complications, including endovascular leak (endoleak), graft migration, stent fracture, and mechanical damage to the access artery and aortic wall.
The Talent stent graft (manufactured by Medtronic Inc., Minneapolis, MN) is licensed in Canada for the treatment of patients with TAA (Class 4; licence 36552). The design of this device has evolved since its clinical introduction. The current version has a more flexible delivery catheter than did the original system. The prosthesis is composed of nitinol stents between thin layers of polyester graft material. Each stent is secured with oversewn sutures to prevent migration.
Review Strategy
Objectives
To compare the effectiveness and cost-effectiveness of ESG placement in the treatment of TAAs with a conventional surgical approach
To summarize the safety profile and effectiveness of ESG placement in the treatment of descending TAAs
Measures of Effectiveness
Primary Outcome
Mortality rates (30-day and longer term)
Secondary Outcomes
Technical success rate of introducing a stent graft and exclusion of the aneurysm sac from systemic circulation
Rate of reintervention (through surgical or endovascular approach)
Measures of Safety
Complications were categorized into 2 classes:
Those specific to the ESG procedure, including rates of aneurysm rupture, endoleak, graft migration, stent fracture, and kinking; and
Those due to the intervention, either surgical or endovascular. These include paraplegia, stroke, cardiovascular events, respiratory failure, real insufficiency, and intestinal ischemia.
Inclusion Criteria
Studies comparing the clinical outcomes of ESG treatment with surgical approaches
Studies reporting on the safety and effectiveness of the ESG procedure for the treatment of descending TAAs
Exclusion Criteria
Studies investigating the clinical effectiveness of ESG placement for other conditions such as aortic dissection, aortic ulcer, and traumatic injuries of the thoracic aorta
Studies investigating the aneurysms of the ascending and the arch of the aorta
Studies using custom-made grafts
Literature Search
The Medical Advisory Secretariat searched The International Network of Agencies for Health Technology Assessment and the Cochrane Database of Systematic Reviews for health technology assessments. It also searched MEDLINE, EMBASE, Medline In-Process & Other Non-Indexed Citations, and Cochrane CENTRAL from January 1, 2000 to July 11, 2005 for studies on ESG procedures. The search was limited to English-language articles and human studies.
One health technology assessment from the United Kingdom was identified. This systematic review included all pathologies of the thoracic aorta; therefore, it did not match the inclusion criteria. The search yielded 435 citations; of these, 9 studies met inclusion criteria.
Summary of Findings
Mortality
The results of a comparative study found that in-hospital mortality was not significantly different between ESG placement and surgery patients (2 [4.8%] for ESG vs. 6 [11.3%] for surgery).
Pooled data from case series with a mean follow-up ranging from 12 to 38 months showed a 30-day mortality and late mortality rate of 3.9% and 5.5%, respectively. These rates are lower than are those reported in the literature for surgical repair of TAA.
Case series showed that the most common cause of early death in patients undergoing endovascular repair is aortic rupture, and the most common causes of late death are cardiac events and aortoesophageal or aortobronchial fistula.
Technical Success Rate
Technical success rates reported by case series are 55% to 100% (100% and 94.4% in 2 studies with all elective cases, 89% in a study with 5% emergent cases, and 55% in a study with 42% emergent cases).
Surgical Reintervention
In the comparative study, 3 (7.1%) patients in the ESG group and 14 (26.5%) patients in the surgery group required surgical reintervention. In the ESG group, the reasons for surgical intervention were postoperative bleeding at the access site, paraplegia, and type 1 endoleak. In the surgical group, the reasons for surgery were duodenal perforation, persistent thoracic duct leakage, false aneurysm, and 11 cases of postoperative bleeding.
Pooled data from case series show that 9 (2.6%) patients required surgical intervention. The reasons for surgical intervention were endoleak (3 cases), aneurysm enlargement and suspected infection (1 case), aortic dissection (1 case), pseudoaneurysm of common femoral artery (1 case), evacuation of hematoma (1 case), graft migration (1 case), and injury to the access site (1 case).
Endovascular Revision
In the comparative study, 3 (7.1%) patients required endovascular revision due to persistent endoleak.
Pooled data from case series show that 19 (5.3%) patients required endovascular revision due to persistent endoleak.
Graft Migration
Two case series reported graft migration. In one study, 3 proximal and 4 component migrations were noted at 2-year follow-up (total of 5%). Another study reported 1 (3.7%) case of graft migration. Overall, the incidence of graft migration was 2.6%.
Aortic Rupture
In the comparative study, aortic rupture due to bare stent occurred in 1 case (2%). The pooled incidence of aortic rupture or dissection reported by case series was 1.4%.
Postprocedural Complications
In the comparative study, there were no statistically significant differences between the ESG and surgery groups in postprocedural complications, except for pneumonia. The rate of pneumonia was 9% for those who received an ESG and 28% for those who had surgery (P = .02). There were no cases of paraplegia in either group. The rate of other complications for ESG and surgery including stroke, cardiac, respiratory, and intestinal ischemia were all 5.1% for ESG placement and 10% for surgery. The rate for mild renal failure was 16% in the ESG group and 30% in the surgery group. The rate for severe renal failure was 11% for ESG placement and 10% for surgery.
Pooled data from case series show the following postprocedural complication rates in the ESG placement group: paraplegia (2.2%), stroke (3.9%), cardiac (2.9%), respiratory (8.7%), renal failure (2.8%), and intestinal ischemia (1%).
Time-Related Outcomes
The results of the comparative study show statistically significant differences between the ESG and surgery group for mean operative time (ESG, 2.7 hours; surgery, 5 hours), mean duration of intensive care unit stay (ESG, 11 days; surgery, 14 days), and mean length of hospital stay (ESG, 10 days; surgery, 30 days).
The mean duration of intensive care unit stay and hospital stay derived from case series is 1.6 and 7.8 days, respectively.
Ontario-Based Economic Analysis
In Ontario, the annual treatment figures for fiscal year 2004 include 17 cases of descending TAA repair procedures (source: Provincial Health Planning Database). Fourteen of these have been identified as “not ruptured” with a mean hospital length of stay of 9.23 days, and 3 cases have been identified as “ruptured,” with a mean hospital length of stay of 28 days. However, because one Canadian Classification of Health Interventions code was used for both procedures, it is not possible to determine how many were repaired with an EVAR procedure or with an open surgical procedure.
Hospitalization Costs
The current fiscal year forecast of in-hospital direct treatment costs for all in-province procedures of repair of descending TAAs is about $560,000 (Cdn). The forecast in-hospital total cost per year for in-province procedures is about $720,000 (Cdn). These costs include the device cost when the procedure is EVAR (source: Ontario Case Costing Initiative).
Professional (Ontario Health Insurance Plan) Costs
Professional costs per treated patient were calculated and include 2 preoperative thoracic surgery or EVAR consultations.
The professional costs of an EVAR include the fees paid to the surgeons, anesthetist, and surgical assistant (source: fee service codes). The procedure was calculated to take about 150 minutes.
The professional costs of an open surgical repair include the fees of the surgeon, anesthetist, and surgical assistant. Open surgical repair was estimated to take about 300 minutes.
Services provided by professionals in intensive care units were also taken into consideration, as were the costs of 2 postoperative consultations that the patients receive on average once they are discharged from the hospital. Therefore, total Ontario Health Insurance Plan costs per treated patient treated with EVAR are on average $2,956 (ruptured or not ruptured), as opposed to $5,824 for open surgical repair and $6,157 for open surgical repair when the aneurysm is ruptured.
Conclusions
Endovascular stent graft placement is a less invasive procedure for repair of TAA than is open surgical repair.
There is no high-quality evidence with long-term follow-up data to support the use of EVAR as the first choice of treatment for patients with TAA that are suitable candidates for surgical intervention.
However, short- and medium-term outcomes of ESG placement reported by several studies are satisfactory and comparable to surgical intervention; therefore, for patients at high risk of surgery, it is a practical option to consider. Short- and medium-term results show that the benefit of ESG placement over the surgical approach is a lower 30-day mortality and paraplegia rate; and shorter operative time, ICU stay, and hospital stay.
PMCID: PMC3382300  PMID: 23074469
2.  Coil Embolization for Intracranial Aneurysms 
Executive Summary
Objective
To determine the effectiveness and cost-effectiveness of coil embolization compared with surgical clipping to treat intracranial aneurysms.
The Technology
Endovascular coil embolization is a percutaneous approach to treat an intracranial aneurysm from within the blood vessel without the need of a craniotomy. In this procedure, a microcatheter is inserted into the femoral artery near the groin and navigated to the site of the aneurysm. Small helical platinum coils are deployed through the microcatheter to fill the aneurysm, and prevent it from further expansion and rupture. Health Canada has approved numerous types of coils and coil delivery systems to treat intracranial aneurysms. The most favoured are controlled detachable coils. Coil embolization may be used with other adjunct endovascular devices such as stents and balloons.
Background
Intracranial Aneurysms
Intracranial aneurysms are the dilation or ballooning of part of a blood vessel in the brain. Intracranial aneurysms range in size from small (<12 mm in diameter) to large (12–25 mm), and to giant (>25 mm). There are 3 main types of aneurysms. Fusiform aneurysms involve the entire circumference of the artery; saccular aneurysms have outpouchings; and dissecting aneurysms have tears in the arterial wall. Berry aneurysms are saccular aneurysms with well-defined necks.
Intracranial aneurysms may occur in any blood vessel of the brain; however, they are most commonly found at the branch points of large arteries that form the circle of Willis at the base of the brain. In 85% to 95% of patients, they are found in the anterior circulation. Aneurysms in the posterior circulation are less frequent, and are more difficult to treat surgically due to inaccessibility.
Most intracranial aneurysms are small and asymptomatic. Large aneurysms may have a mass effect, causing compression on the brain and cranial nerves and neurological deficits. When an intracranial aneurysm ruptures and bleeds, resulting in a subarachnoid hemorrhage (SAH), the mortality rate can be 40% to 50%, with severe morbidity of 10% to 20%. The reported overall risk of rupture is 1.9% per year and is higher for women, cigarette smokers, and cocaine users, and in aneurysms that are symptomatic, greater than 10 mm in diameter, or located in the posterior circulation. If left untreated, there is a considerable risk of repeat hemorrhage in a ruptured aneurysm that results in increased mortality.
In Ontario, intracranial aneurysms occur in about 1% to 4% of the population, and the annual incidence of SAH is about 10 cases per 100,000 people. In 2004-2005, about 660 intracranial aneurysm repairs were performed in Ontario.
Treatment of Intracranial Aneurysms
Treatment of an unruptured aneurysm attempts to prevent the aneurysm from rupturing. The treatment of a ruptured intracranial aneurysm aims to prevent further hemorrhage. There are 3 approaches to treating an intracranial aneurysm.
Small, asymptomatic aneurysms less than 10 mm in diameter may be monitored without any intervention other than treatment for underlying risk factors such as hypertension.
Open surgical clipping, involves craniotomy, brain retraction, and placement of a silver clip across the neck of the aneurysm while a patient is under general anesthesia. This procedure is associated with surgical risks and neurological deficits.
Endovascular coil embolization, introduced in the 1990s, is the health technology under review.
Literature Review
Methods
The Medical Advisory Secretariat searched the International Health Technology Assessment (INAHTA) Database and the Cochrane Database of Systematic Reviews to identify relevant systematic reviews. OVID Medline, Medline In-Process and Other Non-Indexed Citations, and Embase were searched for English-language journal articles that reported primary data on the effectiveness or cost-effectiveness of treatments for intracranial aneurysms, obtained in a clinical setting or analyses of primary data maintained in registers or institutional databases. Internet searches of Medscape and manufacturers’ databases were conducted to identify product information and recent reports on trials that were unpublished but that were presented at international conferences. Four systematic reviews, 3 reports on 2 randomized controlled trials comparing coil embolization with surgical clipping of ruptured aneurysms, 30 observational studies, and 3 economic analysis reports were included in this review.
Results
Safety and Effectiveness
Coil embolization appears to be a safe procedure. Complications associated with coil embolization ranged from 8.6% to 18.6% with a median of about 10.6%. Observational studies showed that coil embolization is associated with lower complication rates than surgical clipping (permanent complication 3-7% versus 10.9%; overall 23% versus 46% respectively, p=0.009). Common complications of coil embolization are thrombo-embolic events (2.5%–14.5%), perforation of aneurysm (2.3%–4.7%), parent artery obstruction (2%–3%), collapsed coils (8%), coil malposition (14.6%), and coil migration (0.5%–3%).
Randomized controlled trials showed that for ruptured intracranial aneurysms with SAH, suitable for both coil embolization and surgical clipping (mostly saccular aneurysms <10 mm in diameter located in the anterior circulation) in people with good clinical condition:Coil embolization resulted in a statistically significant 23.9% relative risk reduction and 7% absolute risk reduction in the composite rate of death and dependency compared to surgical clipping (modified Rankin score 3–6) at 1-year.
The advantage of coil embolization over surgical clipping varies widely with aneurysm location, but endovascular treatment seems beneficial for all sites.
There were less deaths in the first 7 years following coil embolization compared to surgical clipping (10.8% vs 13.7%). This survival benefit seemed to be consistent over time, and was statistically significant (log-rank p= 0.03).
Coil embolization is associated with less frequent MRI-detected superficial brain deficits and ischemic lesions at 1-year.
The 1- year rebleeding rate was 2.4% after coil embolization and 1% for surgical clipping. Confirmed rebleeding from the repaired aneurysm after the first year and up to year eight was low and not significantly different between coil embolization and surgical clipping (7 patients for coil embolization vs 2 patients for surgical clipping, log-rank p=0.22).
Observational studies showed that patients with SAH and good clinical grade had better 6-month outcomes and lower risk of symptomatic cerebral vasospasm after coil embolization compared to surgical clipping.
For unruptured intracranial aneurysms, there were no randomized controlled trials that compared coil embolization to surgical clipping. Large observational studies showed that:
The risk of rupture in unruptured aneurysms less than 10 mm in diameter is about 0.05% per year for patients with no pervious history of SAH from another aneurysm. The risk of rupture increases with history of SAH and as the diameter of the aneurysm reaches 10 mm or more.
Coil embolization reduced the composite rate of in hospital deaths and discharge to long-term or short-term care facilities compared to surgical clipping (Odds Ratio 2.2, 95% CI 1.6–3.1, p<0.001). The improvement in discharge disposition was highest in people older than 65 years.
In-hospital mortality rate following treatment of intracranial aneurysm ranged from 0.5% to 1.7% for coil embolization and from 2.1% to 3.5% for surgical clipping. The overall 1-year mortality rate was 3.1% for coil embolization and 2.3% for surgical clipping. One-year morbidity rate was 6.4% for coil embolization and 9.8% for surgical clipping. It is not clear whether these differences were statistically significant.
Coil embolization is associated with shorter hospital stay compared to surgical clipping.
For both ruptured and unruptured aneurysms, the outcome of coil embolization does not appear to be dependent on age, whereas surgical clipping has been shown to yield worse outcome for patients older than 64 years.
Angiographic Efficiency and Recurrences
The main drawback of coil embolization is its low angiographic efficiency. The percentage of complete aneurysm occlusion after coil embolization (27%–79%, median 55%) remains lower than that achieved with surgical clipping (82%–100%). However, about 90% of coiled aneurysms achieve near total occlusion or better. Incompletely coiled aneurysms have been shown to have higher aneurysm recurrence rates ranging from 7% to 39% for coil embolization compared to 2.9% for surgical clipping. Recurrence is defined as refilling of the neck, sac, or dome of a successfully treated aneurysm as shown on an angiogram. The long-term clinical significance of incomplete occlusion following coil embolization is unknown, but in one case series, 20% of patients had major recurrences, and 50% of these required further treatment.
Long-Term Outcomes
A large international randomized trial reported that the survival benefit from coil embolization was sustained for at least 7 years. The rebleeding rate between year 2 and year 8 following coil embolization was low and not significantly different from that of surgical clipping. However, high quality long-term angiographic evidence is lacking. Accordingly, there is uncertainty about long-term occlusion status, coil durability, and recurrence rates. While surgical clipping is associated with higher immediate procedural risks, its long-term effectiveness has been established.
Indications and Contraindications
Coil embolization offers treatment for people at increased risk for craniotomy, such as those over 65 years of age, with poor clinical status, or with comorbid conditions. The technology also makes it possible to treat surgical high-risk aneurysms.
Not all aneurysms are suitable for coil embolization. Suitability depends on the size, anatomy, and location of the aneurysm. Aneurysms more than 10 mm in diameter or with an aneurysm neck greater than or equal to 4 mm are less likely to achieve total occlusion. They are also more prone to aneurysm recurrences and to complications such as coil compaction or parent vessel occlusion. Aneurysms with a dome to neck ratio of less than 1 have been shown to have lower obliteration rates and poorer outcome following coil embolization. Furthermore, aneurysms in the middle cerebral artery bifurcation are less suitable for coil embolization. For some aneurysms, treatment may require the use of both coil embolization and surgical clipping or adjunctive technologies, such as stents and balloons, to obtain optimal results.
Diffusion
Information from 3 countries indicates that coil embolization is a rapidly diffusing technology. For example, it accounted for about 40% of aneurysm treatments in the United Kingdom.
In Ontario, coil embolization is an insured health service, with the same fee code and fee schedule as open surgical repair requiring craniotomy. Other costs associated with coil embolization are covered under hospitals’ global budgets. Utilization data showed that in 2004-2005, coil embolization accounted for about 38% (251 cases) of all intracranial aneurysm repairs in the province. With the 2005 publication of the positive long-term survival data from the International Subarachnoid Aneursym Trial, the pressure for diffusion will likely increase.
Economic Analysis
Recent economic studies show that treatment of unruptured intracranial aneurysms smaller than 10 mm in diameter in people with no previous history of SAH, either by coil embolization or surgical clipping, would not be effective or cost-effective. However, in patients with aneurysms that are greater than or equal to 10 mm or symptomatic, or in patients with a history of SAH, treatment appears to be cost-effective.
In Ontario, the average device cost of coil embolization per case was estimated to be about $7,500 higher than surgical clipping. Assuming that the total number of intracranial aneurysm repairs in Ontario increases to 750 in the fiscal year of 2007, and assuming that up to 60% (450 cases) of these will be repaired by coil embolization, the difference in device costs for the 450 cases (including a 15% recurrence rate) would be approximately $3.8 million. This figure does not include capital costs (e.g. $3 million for an angiosuite), additional human resources required, or costs of follow-up. The increase in expenditures associated with coil embolization may be offset partially, by shorter operating room times and hospitalization stays for endovascular repair of unruptured aneurysms; however, the impact of these cost savings is probably not likely to be greater than 25% of the total outlay since the majority of cases involve ruptured aneurysms. Furthermore, the recent growth in aneurysm repair has predominantly been in the area of coil embolization presumably for patients for whom surgical clipping would not be advised; therefore, no offset of surgical clipping costs could be applied in such cases. For ruptured aneurysms, downstream cost savings from endovascular repair are likely to be minimal even though the savings for individual cases may be substantial due to lower perioperative complications for endovascular aneurysm repair.
Guidelines
The two Guidance documents issued by the National Institute of Clinical Excellence (UK) in 2005 support the use of coil embolization for both unruptured and ruptured (SAH) intracranial aneurysms, provided that procedures are in place for informed consent, audit, and clinical governance, and that the procedure is performed in specialist units with expertise in the endovascular treatment of intracranial aneurysms.
Conclusion
For people in good clinical condition following subarachnoid hemorrhage from an acute ruptured intracranial aneurysm suitable for either surgical clipping or endovascular repair, coil embolization results in improved independent survival in the first year and improved survival for up to seven years compared to surgical clipping. The rebleeding rate is low and not significantly different between the two procedures after the first year. However, there is uncertainty regarding the long-term occlusion status, durability of the stent graft, and long-term complications.
For people with unruptured aneurysms, level 4 evidence suggests that coil embolization may be associated with comparable or less mortality and morbidity, shorter hospital stay, and less need for discharge to short-term rehabilitation facilities. The greatest benefit was observed in people over 65 years of age. In these patients, the decision regarding treatment needs to be based on the assessment of the risk of rupture against the risk of the procedure, as well as the morphology of the aneurysm.
In people who require treatment for intracranial aneurysm, but for whom surgical clipping is too risky or not feasible, coil embolization provides survival benefits over surgical clipping, even though the outcomes may not be as favourable as in people in good clinical condition and with small aneurysms. The procedure may be considered under the following circumstances provided that the aneurysm is suitable for coil embolization:
Patients in poor/unstable clinical or neurological state
Patients at high risk for surgical repair (e.g. people>age 65 or with comorbidity), or
Aneurysm(s) with poor accessibility or visibility for surgical treatment due to their location (e.g. ophthalmic or basilar tip aneurysms)
Compared to small aneurysms with a narrow neck in the anterior circulation, large aneurysms (> 10 mm in diameter), aneurysms with a wide neck (>4mm in diameter), and aneurysms in the posterior circulation have lower occlusion rates and higher rate of hemorrhage when treated with coil embolization.
The extent of aneurysm obliteration after coil embolization remains lower than that achieved with surgical clipping. Aneurysm recurrences after successful coiling may require repeat treatment with endovascular or surgical procedures. Experts caution that long-term angiographic outcomes of coil embolization are unknown at this time. Informed consent for and long-term follow-up after coil embolization are recommended.
The decision to treat an intracranial aneurysm with surgical clipping or coil embolization needs to be made jointly by the neurosurgeon and neuro-intervention specialist, based on the clinical status of the patient, the size and morphology of the aneurysm, and the preference of the patient.
The performance of endovascular coil embolization should take place in centres with expertise in both neurosurgery and endovascular neuro-interventions, with adequate treatment volumes to maintain good outcomes. Distribution of the technology should also take into account that patients with SAH should be treated as soon as possible with minimal disruption.
PMCID: PMC3379525  PMID: 23074479
3.  Endovascular Repair of Abdominal Aortic Aneurysm 
EXECUTIVE SUMMARY
The Medical Advisory Secretariat conducted a systematic review of the evidence on the effectiveness and cost-effectiveness of endovascular repair of abdominal aortic aneurysm in comparison to open surgical repair. An abdominal aortic aneurysm [AAA] is the enlargement and weakening of the aorta (major blood artery) that may rupture and result in stroke and death. Endovascular abdominal aortic aneurysm repair [EVAR] is a procedure for repairing abdominal aortic aneurysms from within the blood vessel without open surgery. In this procedure, an aneurysm is excluded from blood circulation by an endograft (a device) delivered to the site of the aneurysm via a catheter inserted into an artery in the groin. The Medical Advisory Secretariat conducted a review of the evidence on the effectiveness and cost-effectiveness of this technology. The review included 44 eligible articles out of 489 citations identified through a systematic literature search. Most of the research evidence is based on non-randomized comparative studies and case series. In the short-term, EVAR appears to be safe and comparable to open surgical repair in terms of survival. It is associated with less severe hemodynamic changes, less blood transfusion and shorter stay in the intensive care and hospital. However, there is concern about a high incidence of endoleak, requiring secondary interventions, and in some cases, conversion to open surgical repair. Current evidence does not support the use of EVAR in all patients. EVAR might benefit individuals who are not fit for surgical repair of abdominal aortic aneurysm and whose risk of rupture of the aneurysm outweighs the risk of death from EVAR. The long-term effectiveness and cost-effectiveness of EVAR cannot be determined at this time. Further evaluation of this technology is required.
OBJECTIVE
The objective of this health technology policy assessment was to determine the effectiveness and cost-effectiveness of endovascular repair of abdominal aortic aneurysms (EVAR) in comparison to open surgical repair (OSR).
BACKGROUND
Clinical Need
An abdominal aortic aneurysm (AAA) is a localized, abnormal dilatation of the aorta greater than 3 cm or 50% of the aortic diameter at the diaphragm. (1) A true AAA involves all 3 layers of the vessel wall. If left untreated, the continuing extension and thinning of the vessel wall may eventually result in rupture of the AAA. The risk of death from ruptured AAA is 80% to 90%. (61) Heller et al. (44) analyzed information from a national hospital database in the United States. They found no significant change in the incidence rate of elective AAA repair or ruptured AAA presented to the nation’s hospitals. The investigators concluded that technologic and treatment advances over the past 19 years have not affected the outcomes of patients with AAAs, and the ability to identify and to treat patients with AAAs has not improved.
Classification of Abdominal Aortic Aneurysms
At least 90% of the AAAs are affected by atherosclerosis, and most of these aneurysms are below the level of the renal arteries.(1)
An abdominal aortic aneurysm may be symptomatic or asymptomatic. An AAA may be classified according to their sizes:(7)
Small aneurysms: less than 5 cm in diameter.
Medium aneurysms: 5-7cm.
Large aneurysms: more than 7 cm in diameter.
Small aneurysms account for approximately 50% of all clinically recognized aneurysms.(7)
Aortic aneurysms may be classified according to their gross appearance as follows (1):
Fusiform aneurysms affect the entire circumference of a vessel, resulting in a diffusely dilated lesion
Saccular aneurysms involve only a portion of the circumference, resulting in an outpouching (protrusion) in the vessel wall.
Prevalence of Abdominal Aortic Aneurysms
In community surveys, the prevalence of AAA is reported to be between 1% and 5.4%. (61) The prevalence is related to age and vascular risk factors. It is more common in men and in those with a positive family history.
In Canada, Abdominal aortic aneurysms are the 10th leading cause of death in men 65 years of age or older. (60) Naylor (60) reported that the rate of AAA repair in Ontario has increased from 38 per 100,000 population in 1981/1982 to 54 per 100,000 population in 1991/1992. For the period of 1989/90 to 1991/92, the rate of AAA repair in Ontarians age 45 years and over was 53 per 100,000. (60) In the United States, about 200,000 new cases are diagnosed each year, and 50,000 to 60,000 surgical AAA repairs are performed. (2) Ruptured AAAs are responsible for about 15,000 deaths in the United States annually. One in 10 men older than 80 years has some aneurysmal change in his aorta. (2)
Symptoms of Abdominal Aortic Aneurysms
AAAs usually do not produce symptoms. However, as they expand, they may become painful. Compression or erosion of adjacent tissue by aneurysms also may cause symptoms. The formation of mural thrombi, a type of blood clots, within the aneurysm may predispose people to peripheral embolization, where blood vessels become blocked. Occasionally, an aneurysm may leak into the vessel wall and the periadventitial area, causing pain and local tenderness. More often, acute rupture occurs without any prior warning, causing acute pain and hypotension. This complication is always life-threatening and requires an emergency operation.
Diagnosis of Abdominal Aortic Aneurysms
An AAA is usually detected on routine examination as a palpable, pulsatile, and non-tender mass. (1)
Abdominal radiography may show the calcified outline of the aneurysms; however, about 25% of aneurysms are not calcified and cannot be visualized by plain x-ray. (1) An abdominal ultrasound provides more accurate detection, can delineate the traverse and longitudinal dimensions of the aneurysm, and is useful for serial documentation of aneurysm size. Computed tomography and magnetic resonance have also been used for follow-up of aortic aneurysms. These technologies, particularly contrast-enhanced computer tomography, provide higher resolution than ultrasound.
Abdominal aortography remains the gold standard to evaluate patients with aneurysms for surgery. This technique helps document the extent of the aneurysms, especially their upper and lower limits. It also helps show the extent of associated athereosclerotic vascular disease. However, the procedure carries a small risk of complications, such as bleeding, allergic reactions, and atheroembolism. (1)
Prognosis of Abdominal Aortic Aneurysms
The risk of rupture of an untreated AAA is a continuous function of aneurysm size as represented by the maximal diameter of the AAA. The annual rupture rate is near zero for aneurysms less than 4 cm in diameter. The risk is about 1% per year for aneurysms 4 to 4.9 cm, 11% per year for aneurysms 5 to 5.9 cm, and 25% per year or more for aneurysms greater than 6 cm. (7)
The 1-year mortality rate of patients with AAAs who do not undergo surgical treatment is about 25% if the aneurysms are 4 to 6 cm in diameter. This increases to 50% for aneurysms exceeding 6 cm. Other major causes of mortality for people with AAAs include coronary heart disease and stroke.
Treatment of Abdominal Aortic Aneurysms
Treatment of an aneurysm is indicated under any one of the following conditions:
The AAA is greater than 6 cm in diameter.
The patient is symptomatic.
The AAA is rapidly expanding irrespective of the absolute diameter.
Open surgical repair of AAA is still the gold standard. It is a major operation involving the excision of dilated area and placement of a sutured woven graft. The surgery may be performed under emergent situation following the rupture of an AAA, or it may be performed electively.
Elective OSR is generally considered appropriate for healthy patients with aneurysms 5 to 6 cm in diameter. (7) Coronary artery disease is the major underlying illness contributing to morbidity and mortality in OSR. Other medical comorbidities, such as chronic renal failure, chronic lung disease, and liver cirrhosis with portal hypertension, may double or triple the usual risk of OSR.
Serial noninvasive follow-up of small aneurysms (less than 5 cm) is an alternative to immediate surgery.
Endovascular repair of AAA is the third treatment option and is the topic of this review.
PMCID: PMC3387737  PMID: 23074438
4.  Ortner's Syndrome: Secondary Laryngeal Paralysis Caused by a Great Thoracic Aorta Aneurysm 
Introduction Recurrent laryngeal nerve injury caused by cardiovascular disease is a rare condition, and often it is the only prominent sign of an imminent break of an aortic artery aneurysm.
Objective To report left laryngeal paralysis caused by a great aortic arch aneurysm and to highlight the importance of an otorhinolaryngologic evaluation along with a thoracic radiologic study.
Resumed Report A 42-year-old man complained of thickness of his voice and dysphagia for 3 months, but no thoracic pain or other relevant complaints. Video laryngoscopy revealed immobility of his left vocal fold in the paramedian position. Imaging was obtained for investigation, including magnetic resonance imaging of his thorax, which showed a fusiform aneurysm in the aortic arch, leading to recurrent compression of the left laryngeal nerve. The patient was successfully treated with endovascular repair of the aneurysm. At 2-month follow-up, there was still no recovery of the laryngeal mobility.
Conclusion An aortic artery aneurysm can suddenly break, requiring emergency heart surgery, and the results can be fatal in many cases. We suggest routine exam of the vocal folds in all patients with a heart condition, and we review the literature and suggest the use of imaging to reduce the number of emergency procedures.
doi:10.1055/s-0034-1397331
PMCID: PMC4399202  PMID: 25992177
vocal cord palsy; arch of the aorta; dysphonia
5.  Ortner’s syndrome presenting as thoracic aortic aneurysm mimicking thoracic malignancy: a case report 
Introduction
Ortner’s syndrome is defined as left recurrent laryngeal nerve palsy caused by a cardiovascular pathology. Here we report the case of a 68-year-old man who presented to our hospital with hoarseness, whose initial chest imaging mimicked a thoracic neoplastic process with left pleural effusion. The final diagnosis was Ortner’s syndrome due to the silent rupture of a thoracoabdominal aortic aneurysm. Diagnostic thoracentesis, before computed tomography, in resource-poor settings, may have resulted in an adverse outcome in our case.
Case presentation
A 68-year-old Sri Lankan man was referred to us by an otolaryngologist for further evaluation of a suspected thoracic malignancy. His presenting symptom was hoarseness of three months duration. He had essential hypertension for the last four years and had a history of 25 pack-years of cigarettes smoking. His chest X-ray showed a left-sided mediastinal mass with mild to moderate pleural effusion. An ultrasound appeared to show an encysted pleural fluid collection. However, we proceeded with computed tomography before diagnostic thoracentesis. The diagnosis of Ortner’s syndrome was made after the computed tomography due to the silent rupture of his thoracoabdominal aortic aneurysm.
Conclusions
Hoarseness due to left recurrent laryngeal nerve palsy can be the presenting symptom of cardiovascular pathologies, Ortner’s syndrome. Silent rupture of thoracic aortic aneurysms can mimic that of thoracic malignancy, which is reported in literature. We illustrate the importance of a high degree of suspicion of cardiovascular pathology in order to avoid an adverse outcome following diagnostic thoracentesis.
doi:10.1186/s13256-015-0629-1
PMCID: PMC4481080  PMID: 26104067
Hoarseness; Ortner’s syndrome; Aortic aneurysm; Thoracic malignancy
6.  Ascending aortic aneurysm causing hoarse voice: a variant of Ortner's syndrome 
BMJ Case Reports  2012;2012:bcr2012007111.
A 68-year-old man with a persistent hoarse voice was found to have a left vocal cord paralysis. Clinical examination revealed signs consistent with aortic regurgitation. Subsequent investigation revealed an ascending aortic aneurysm. He underwent aortic root and ascending aorta replacement and his hoarseness improved. Ortner's syndrome refers to hoarseness due to recurrent laryngeal nerve palsy secondary to a cardiovascular abnormality. Recurrent laryngeal nerve palsy due to aneurysmal dilation of the ascending aorta is extremely rare, with aneurysms of the aortic arch being a more common cause.
doi:10.1136/bcr-2012-007111
PMCID: PMC4544936  PMID: 23060380
7.  Acute Contained Ruptured Aortic Aneurysm Presenting as Left Vocal Fold Immobility 
Case Reports in Otolaryngology  2015;2015:219090.
Objective. To recognize intrathoracic abnormalities, including expansion or rupture of aortic aneurysms, as a source of acute onset vocal fold immobility. Methods. A case report and review of the literature. Results. An 85-year-old female with prior history of an aortic aneurysm presented to a tertiary care facility with sudden onset hoarseness. On laryngoscopy, the left vocal fold was immobile in the paramedian position. A CT scan obtained that day revealed a new, large hematoma surrounding the upper descending aortic stent graft consistent with an acute contained ruptured aortic aneurysm. She was referred to the emergency department for evaluation and treatment by vascular surgery. She was counseled regarding surgical options and ultimately decided not to pursue further treatment. Her vocal fold immobility was subsequently treated via office-based injection medialization two weeks after presentation and again 5 months after the initial injection which dramatically improved her voice. Follow-up CT scan at 8 months demonstrated a reduction of the hematoma. The left vocal cord remains immobile to date. Conclusion. Ortner's syndrome, or cardiovocal syndrome, is hoarseness secondary to left recurrent laryngeal nerve palsy caused by cardiovascular pathology. It is a rare condition and, while typically presenting gradually, may also present with acute symptomatology.
doi:10.1155/2015/219090
PMCID: PMC4306210  PMID: 25648215
8.  Hoarseness as the sole symptom of an impending thoracic aneurysm rupture? 
Unilateral vocal cord palsy secondary to thoracic aortic aneurysm is a rare occurrence. Direct compression of the enlarging thoracic aneurysm on the left recurrent laryngeal nerve causes neuronal injury of the nerve, which is manifested as hoarseness. We present a rare case of unilateral vocal cord palsy in a 60-year-old healthy gentleman caused by a large thoracic aortic aneurysm. This rare presentation, with a serious underlying pathology might be misdiagnosed or delayed. Therefore, it is important for us to have high index of suspicion in cases with a rare presentation such as this.
PMCID: PMC4265966  PMID: 25606294
thoracic aneurysm; hoarseness; vocal cord palsy
9.  Proximal clamping levels in abdominal aortic aneurysm surgery. 
Texas Heart Institute Journal  1999;26(4):264-268.
In the surgical treatment of abdominal aortic aneurysm, the single proximal cross-clamp can be placed at 3 alternative aortic levels: infrarenal, hiatal, and thoracic. We performed this retrospective study to evaluate the advantages and disadvantages of the 3 main aortic clamping locations. Eighty patients presented at our institution with abdominal aortic aneurysms from March 1993 through May 1998. Fifty of these patients had intact aneurysms and underwent elective surgery, and 30 had ruptured aneurysms that necessitated emergency surgery. Proximal aortic clamping was applied at the infrarenal level in 24 patients (22 from the intact aneurysm group, 2 from the ruptured group), at the hiatal level in 34 patients (22 intact, 12 ruptured), and at the thoracic level (descending aorta) via a limited left lateral thoracotomy in 22 patients (6 intact, 16 ruptured). Early mortality rates (within 30 days) were 4% (2 of 50 patients) among patients with intact aneurysms and 40% (12 of 30 patients) among those with ruptured aneurysms. In the 2 patients from the intact aneurysm group, proximal aortic clamps were applied at the hiatal level. In the ruptured aneurysm group, proximal aortic clamps were placed at the thoracic level in 10 patients, the infrarenal level in 1, and the hiatal level in 1. According to our study, the clinical status of the patient and the degree of operative urgency--as determined by the extent of the aneurysm--generally dictate the proximal clamp location. Patients who present with aneurysmal rupture or hypovolemic shock benefit from thoracic clamping, because it restores the blood pressure and allows time to replace the volume deficit. Infrarenal placement is advantageous in patients with intact aneurysms if there is sufficient space for the clamp between the renal arteries and the aortic aneurysm. In patients with juxtarenal aneurysms, hiatal clamping enables safe and easy anastomosis to the healthy aorta. Clamping at this level also helps prevent late anastomotic aneurysm formation, which is frequently encountered after inadvertent anastomosis of the graft to a diseased portion of the aorta. Further studies are needed in order to confirm these results.
PMCID: PMC325661  PMID: 10653253
10.  Ortner's syndrome 
BMJ Case Reports  2014;2014:bcr2013200950.
A 42-year-old man with a significant smoking history presented with chronic expectorative cough and exertional shortness of breath with recent-onset hoarseness. Chest examination was essentially normal and cardiovascular examination was suggestive of aortic regurgitation. Ears, nose and throat evaluation showed left vocal cord palsy and CT scan revealed an aortic arch aneurysm. Ortner's syndrome refers to hoarseness due to recurrent laryngeal nerve palsy secondary to a cardiovascular abnormality. Aortic aneurysms usually present with chest pain, back pain or epigastric pain, depending on the site of the aneurysm. An aortic arch aneurysm presenting as hoarseness is extremely rare.
doi:10.1136/bcr-2013-200950
PMCID: PMC3962976  PMID: 24618861
11.  Right Phrenic Nerve Palsy: A Rare Presentation of Thoracic Aortic Aneurysm 
Phrenic nerve palsy causing hemidiaphragm paralysis is a very uncommon feature of thoracic aortic aneurysm. In one case, a 45-year-old man complained of chronic chest pain, dysphagia, and hoarseness of voice; posteroanterior view chest radiograph revealed lobular enlargement of the superior mediastinum and elevated right hemidiaphragm. Contrast-enhanced computed tomography (CT) of the thorax revealed a giant partially thrombosed aneurysm originating from the ascending aorta and extending into the aortic arch, causing a widening of the aorta-pulmonary window and a compression of the thoracic esophagus. Right hemidiaphragm elevation was explained by the gross mass effect of the aneurysm on the right hilum, causing right phrenic nerve palsy. The patient was to be operated on for surgical correction of the aneurysm, but died before surgery due to spontaneous rupture.
PMCID: PMC3773361  PMID: 24044005
dysphagia; hoarseness; thoracic aortic aneurysm; palsy; phrenic nerve
12.  Hoarseness —As a presenting feature of aortic arch aneurysm 
Hoarseness due to left recurrent laryngeal nerve paralysis (LRLN) caused by identifiable cardiovascular disease is described as Ortner’s syndrome or Cardiovocal syndrome. This was first described by Ortner in 1897 to describe left recurrent laryngeal nerve palsy secondary to Mitral Stenosis. The common conditions which gave rise to Ortners’ syndrome include mitral stenosis, mitral valve prolapse, aortic aneurysm, septal defect, following cardiothoracic surgery, high altitude pulmonary hypertension, ductal aneurysm, aortic dissection etc. Herewith we are presenting an unusual presentation of Aortic arch aneurysm.
doi:10.1007/BF03050855
PMCID: PMC3450419  PMID: 23120328
Aortic arch aneurym; laryngeal nerve paralysis
13.  Ruptured Thoracic Aortic Aneurysm Infected with Listeria Monocytogenes: A Case Report and a Review of Literature 
A 75-year-old male with a history of alcoholic liver cirrhosis, sigmoid colon cancer, and metastatic liver cancer was admitted to our institution with a complaint of a prickly feeling in his chest. On admission, a chest radiograph revealed a normal cardio-thoracic ratio of 47%. Echocardiography revealed pericardial effusion and blood chemical analyses revealed elevated C-reactive protein levels (14.7 mg/dL). On day 3, chest radiography revealed cardiomegaly with a cardio-thoracic ratio of 58% and protrusion of the left first arch. Contrast-enhanced chest computed tomography revealed a saccular aneurysm in the aortic arch with surrounding hematoma; thus, a ruptured thoracic aortic aneurysm was suspected. Emergency surgery was performed, which revealed a ruptured aortic aneurysm with extensive local inflammation. The diagnosis of an infected aortic rupture was therefore confirmed. The aneurysm and abscess were resected, followed by prosthetic graft replacement and omental packing. Histopathology of the resected aneurysm revealed gram-positive bacilli; and Listeria monocytogenes was confirmed as the causative organism by culture. Postoperative course was uneventful; on postoperative day 60, the patient was ambulatory and was discharged. Here we report the case of a male with a ruptured thoracic aortic aneurysm infected with L. monocytogenes.
doi:10.4137/OJCS.S11446
PMCID: PMC4222319  PMID: 25512697
Thoracic aortic aneurysm; Listeria monocytogenes
14.  11 cm Haughton D left cervical aortic arch aneurysm 
A 56 year old Caucasian man presented with sudden loss of consciousness while driving and was found to have an 11 cm Haughton D type left cervical aortic arch aneurysm with normal brachiocephalic branching and normal descending thoracic laterality but with considerable tortuosity and redundancy of aortic arch. The aneurysm arose between the left common carotid artery and the left subclavian artery. It compressed and stretched the left common carotid artery, compressed the pulmonary trunk and the left pulmonary artery, stretched the vagus, left recurrent laryngeal and left phrenic nerves and caused extreme deviation of trachea, severely compromising the tracheal lumen. Patient underwent successful interposition graft replacement of distal aortic arch under total circulatory arrest and selective unihemispherical cerebral perfusion.
doi:10.1186/1749-8090-8-108
PMCID: PMC3639062  PMID: 23618036
15.  Thoracic aortic aneurysm: A rare cause of elevated hemidiaphragm 
Phrenic nerve palsy causing hemidiaphragm paralysis is a very uncommon feature of thoracic aortic aneurysm. In one case, a 30 year male complained of chronic dull aching chest pain, and hoarseness of voice; posteroanterior view chest radiograph revealed large spherical radiopacity on the left upper lung zone with smooth lobulated margin with elevated left hemidiaphragm. On Colour Doppler sonography, lesion was anechoic on gray scale sonography but on Doppler analysis revealed intense internal vascularity within it with characteristic “Ying Yang” sign. The finding favor the vascular origin of the lesion and a diagnosis of an arterial aneurysm was made Contrast-enhanced computed tomography (CT) of the thorax revealed a large well defined spherical lesion of 8 × 10 cm size with smooth well defined margin arising from the aortic arch and attenuation of impending rupture or dissection were lesion on immediate post contrast and delayed scan was similar to that of aorta. Left hemidiaphragm elevation was explained by the gross mass effect of the aneurysm causing right phrenic nerve palsy.
doi:10.4103/0970-2113.184917
PMCID: PMC4948234  PMID: 27578939
Hoarseness; phrenic nerve palsy; thoracic aortic aneurysm
16.  Ultrasound Screening for Abdominal Aortic Aneurysm 
Executive Summary
Objective
The aim of this review was to assess the effectiveness of ultrasound screening for asymptomatic abdominal aortic aneurysm (AAA).
Clinical Need
Abdominal aortic aneurysm is a localized abnormal dilatation of the aorta greater than 3 cm. In community surveys, the prevalence of AAA is reported to be between 2% and 5.4%. Abdominal aortic aneurysms are found in 4% to 8% of older men and in 0.5% to 1.5% of women aged 65 years and older. Abdominal aortic aneurysms are largely asymptomatic. If left untreated, the continuing extension and thinning of the vessel wall may eventually result in rupture of the AAA. Often rupture may occur without warning, causing acute pain. Rupture is always life threatening and requires emergency surgical repair of the ruptured aorta. The risk of death from ruptured AAA is 80% to 90%. Over one-half of all deaths attributed to a ruptured aneurysm take place before the patient reaches hospital. In comparison, the rate of death in people undergoing elective surgery is 5% to 7%; however, symptoms of AAA rarely occur before rupture. Given that ultrasound can reliably visualize the aorta in 99% of the population, and its sensitivity and specificity for diagnosing AAA approaches 100%, screening for aneurysms is worth considering as it may reduce the incidence of ruptured aneurysms and hence reduce unnecessary deaths caused by AAA-attributable mortality.
Review Strategy
The Medical Advisory Secretariat used its standard search strategy to retrieve international health technology assessments and English-language journal articles from selected databases to determine the effectiveness of ultrasound screening for abdominal aortic aneurysms. Case reports, letters, editorials, nonsystematic reviews, non-human studies, and comments were excluded.
Questions asked:
Is population-based AAA screening effective in improving health outcomes in asymptomatic populations?
Is AAA screening acceptable to the population? Does this affect the effectiveness the screening program?
How often should population-based screening occur?
What are appropriate treatment options after screening based on the size of aneurysms?
Are there differences between universal and targeted screening strategies?
What are the harms of screening?
Summary of Findings
Population-based ultrasound screening is effective in men aged 65 to 74 years, particularly in those with a history of smoking. Screening reduces the incidence of AAA ruptures, and decreases rates of emergency surgical repair for AAA and AAA-attributable mortality.
Acceptance rates decline with increasing age and are lower for women. Low acceptance rates may affect the effectiveness of a screening program.
A one-time screen is sufficient for a population-based screening program with regard to initial negative scans and development of large AAAs.
There is no difference between early elective surgical repair and surveillance for small aneurysms (4.0–5.4 cm). Repeated surveillance of small aneurysms is recommended.
Targeted screening based on history of smoking has been found to detect 89% of prevalent AAAs and increase the efficiency of screening programs from statistical modeling data.
Women have not been studied for AAA screening programs. There is evidence suggesting that screening women for AAA should be considered with respect to mortality and case fatality rates in Ontario. It is important that further evaluation of AAAs in women occur.
There is a small risk of physical harm from screening. Less than 1% of aneurysms will not be visualized on initial screen and a re-screen may be necessary; elective surgical repair is associated with a 6% operative morality rate and about 3% of small aneurysms may rupture during surveillance. These risks should be communicated through informed consent prior to screening.
There is little evidence of severe psychological harms associated with screening.
Conclusions
Based on this review, the Medical Advisory Secretariat concluded that there is sufficient evidence to determine that AAA screening using ultrasound is effective and reduces negative health outcomes associated with the condition.
Moreover, screening for AAA is cost-effective, comparing favorably for the cost of per life year gained for screening programs for cervical cancer, hypertension, and breast cancer that are in practice in Ontario, with a high degree of compliance, and can be undertaken with a minimal effort at fewer than 10 minutes to screen each patient.
Overall, the clinical utility of an invitation to use ultrasound screening to identify AAA in men aged 65 to 74 is effective at reducing AAA-attributable mortality. The benefit of screening women is not yet established. However, Ontario data indicate several areas of concern including population prevalence, detection of AAA in women, and case management of AAA in women in terms of age cutoffs for screening and natural history of disease associated with age of rupture.
PMCID: PMC3379169  PMID: 23074490
17.  Thick lung wedge resection for acute life-threatening massive hemoptysis due to aortobronchial fistula 
Journal of Thoracic Disease  2016;8(9):E957-E960.
Massive hemoptysis from an aortobronchial fistula due to thoracic aortic dissection is an extremely rare symptom, but is a potentially life-threatening condition. We report a case of acute massive hemoptysis due to aortobronchial fistula that was successfully controlled by a simple and rapid thick wedge resection of the lung with hematoma by using the black cartilage stapler. A 65-year-old man was admitted to our hospital with acute massive hemoptysis. After tracheal intubation, chest computed tomography revealed hematoma in the left lung and ruptured aortic dissection from the distal arch to the descending aorta. He was diagnosed with aortobronchial fistula and underwent an emergency surgery on the same day. We performed posterolateral thoracotomy. A dissecting aortic aneurysm (diameter, ~80 mm) with adhesion of the left upper lobe and the superior segment of the lower lobe was found. The lung parenchyma expanded with the hematoma. We stapled the upper and lower lobes by using the black cartridge stapler along the aortopulmonary window. Massive hemoptysis disappeared, and the complete aortic dissection appeared. Aortic dissection with adherent lung was excised, and graft replacement of the distal arch and descending thoracic aorta was performed. Proximal lung wedge resection using black cartridge stapler is a simple and quick method to control massive hemoptysis from aortic dissection; hence, this procedure is an effective option to control massive hemoptysis due to aortobronchial fistula. This technique could rapidly stop massive hemoptysis and prevent dissection of the adherent lung tissue and intra-thoracic bleeding.
doi:10.21037/jtd.2016.09.08
PMCID: PMC5059353  PMID: 27747035
Aortobronchial fistula; aortic dissection; wedge resection; hemoptysis
18.  AB 61. Resection of a giant bilateral retrovascular intrathoracic goiter causing severe upper airway obstruction, 2 years after subtotal thyroidectomy a case report and review of the literature 
Journal of Thoracic Disease  2012;4(Suppl 1):AB61.
Background
The intrathoracic (substernal) goiter (1-15% of all thyroidectomies) is usually benign; but it can be malignant in 3-17%. There is history of thyroid surgery in 13-30% of patients. Intrathoracic goiters cause adjacent structure compression more frequently than the cervical goiters, due to the limited space of the thoracic cage. Compression of trachea, oesophagus, vascular and neural structures may cause dyspnoea, dysphagia, superior vena cava syndrome, subclavian vein thrombosis, dysphonia, and Horner’s syndrome. There is usually progressive deterioration, but acute exacerbation may occur. We present successful surgical management of a gigantic benign intrathoracic goiter, causing severe respiratory distress.
Patients and methods
A 63 year old male with history of subtotal thyroidectomy 2 years ago, presented with progressively increasing dyspnoea and inspiratory stridor. A large cervical, and prespinal superior and posterior mediastinal mass was revealed on computed tomography. Two retrovascular, pre- para- and retro-tracheal lobes were displacing the aortic arch, the anonymous vein, and the trachea, descending to the carina, severely compressing the trachea at the level of the aortic arch. Two lobes [maximum length: 12 cm (right), 14 cm (left), total weight: 290 gr] were resected en block through a cervical collar incision and a median sternotomy. Histology revealed multinodular goiter without malignancy.
Results
The operation and the postoperative course were uneventful, without: bleeding, infection, recurrent laryngeal nerve palsy, cardiorespiratory, endocrine, or wound complications. Airway stenosis was immediately relieved, although a minor degree of stenosis, attributed to tracheomalacia due to chronic compression, remained. No intervention was required, and improvement was noted at follow-up.
Conclusions
Thoracic goiter (>50% of the mass below the thoracic inlet) is per se an indication for resection. Tracheal compression by (cervical or thoracic) goiter is also an indication for resection; early tracheal decompression is recommended particularly in symptomatic patients. In severe respiratory distress, intubation and semi-urgent operation may be required. With early intervention, most intrathoracic goiters (91-99%) can be removed through a cervical approach, while tracheomalacia is avoided. Re-operation and resection of a goiter descending to the carina, adjacent to the aortic arch, the descending aorta and the thoracic spine required a median sternotomy that was not associated with morbidity.
doi:10.3978/j.issn.2072-1439.2012.s061
PMCID: PMC3537438
19.  Bronchiectasis and hoarseness of voice in takayasu arteritis: a rare presentation 
BMC Research Notes  2012;5:447.
Background
Takayasu arteritis is a large vessel vasculitis occurring in young females. We report a rare presentation of Takayasu arteritis in a Sri Lankan woman. She presented with bronchiectasis and left recurrent laryngeal nerve palsy prior to the onset of vascular symptoms. This case illustrates an atypical presentation of this disease and the diagnostic dilemma that the physician may be faced with.
Case presentation
A 39-year-old woman presented with chronic cough, haemoptysis and hoarseness of voice. She had left recurrent laryngeal nerve palsy and high inflammatory markers on investigation. CT thorax revealed aortic wall thickening and traction bronchiectasis. 2 D echocardiogram revealed grade 1 aortic regurgitation compatible with aortitis. She did not have weak peripheral pulses or a blood pressure discrepancy and did not meet American College of Rheumatology (ACR) criteria for diagnosis of Takayasu arteritis at this stage. Tuberculosis, syphilis and sarcoidosis was excluded. While awaiting angiography, she developed left arm claudication and a pericardial effusion. Angiography revealed evidence of Takayasu arteritis and absence of flow in the left subclavian artery. Takayasu arteritis was diagnosed at this stage after a period of eight months from the onset of initial symptoms. She is currently on prednisolone, azathioprine and aspirin.
Conclusion
Bronchiectasis and recurrent laryngeal nerve palsy is a rare presentation of Takayasu arteritis. Atypical presentations can occur in Takayasu arteritis prior to the onset of vascular symptoms. Elevation of inflammatory markers are an early finding. A high degree of suspicion is needed to identify these patients in the early course of the disease.
doi:10.1186/1756-0500-5-447
PMCID: PMC3506433  PMID: 22905814
Takayasu arteritis; Bronchiectasis; Recurrent laryngeal nerve palsy; Pericardial effusion
20.  Aneurysm formation at both ends of an endograft associated with maladaptive aortic changes after endovascular aortic repair in a healthy patient 
We report a case in which saccular aneurysms formed at both ends of an endograft that exhibited maladaptive aortic changes after endovascular aortic repair in a patient without significant evidence of connective tissue disease. A 66-year old male underwent thoracic endovascular aortic repair (TEVAR) for a distal aortic arch aneurysm. A follow-up computed tomography (CT) scan performed at 6 months after the TEVAR detected a small saccular aneurysm at the distal edge of the endograft. At 10 months after the TEVAR, a new large aneurysm appeared at the proximal edge of the endograft. To prevent the latter aneurysm rupturing, total arch replacement with endograft fixation was performed. A CT scan obtained at 18 months after the TEVAR demonstrated that the aneurysm at the distal edge of the endograft had progressed and so we considered reintervention. Unfortunately, the patient died of intracranial haemorrhaging before the second procedure could be carried out. A histopathological examination of the aneurysm wall did not detect any significant background factors, such as connective tissue disease, inflammation or infection. The present case involved unexpected late complications, which might have been caused by changes in the form of the aorta after TEVAR.
doi:10.1093/icvts/ivt336
PMCID: PMC3805213  PMID: 23906964
Thoracic endovascular aortic repair; Thoracic aorta
21.  Bilaterally isolated abducens palsy after an aneursym rupture is related with intracranial hypertension 
SpringerPlus  2015;4:765.
Background
Bilateral and isolated abducens nerve palsy is a rare initial presentation after aneurysms rupture. Several possible mechanisms including intracranial hypertension have been purposed. To date, there have been no reports with objective measurements to demonstrate the relationship between intracranial pressure and isolated abducens palsy in the setting of acute subarachnoid hemorrhage due to aneurysm rupture.
Findings
A 50 year-old female presented with severe headache and bilaterally isolated abducens nerve palsy. A series of image studies showed a ruptured aneurysm over right internal carotid artery and posterior communicating artery bifurcation with minimal subarachnoid hemorrhage. Surgery of aneurysm clipping was performed and intracranial pressure monitoring was applied. Postoperatively no new neurological deficit developed but persistent headache and increased intracranial pressure measured by a fiber-optic device had been observed. The intracranial hypertension then decreased gradually with rapid recovery from the bilateral abducens palsy 7 days after the surgery. The relationship between postoperative intracranial pressure, subarachnoid hematoma and isolated abducens palsy are illustrated.
Conclusions
The report demonstrated the clinical presentation of bilaterally isolated abducens palsy after an intracranial aneurysm rupture is related with the increased intracranial pressure level, rather than the hematoma compression to the nerve or vasospasm of pontine branches of basilar artery.
doi:10.1186/s40064-015-1560-z
PMCID: PMC4675756  PMID: 26688779
Abducens palsy; Intracranial pressure; Ruptured aneurysm; Subarachnoid hemorrhage; Neuromonitoring
22.  Case Report: Spontaneous aneurysm of ductus arteriosus: A rare cause of hoarseness of voice in adults 
Ortner's syndrome (left recurrent laryngeal nerve palsy caused by cardiovascular pathology) is described in literature as occurring secondary to a variety of conditions. Spontaneous aneurysm of ductus arteriosus is a rare cause of this condition. We present a case where an adult patient with an aneurysm of the ductus arteriosus presented for the first time at the age of 62 years with hoarseness of voice secondary to left recurrent laryngeal nerve palsy.
doi:10.4103/0971-3026.43853
PMCID: PMC2747459  PMID: 19774192
Aneurysm of ductus arteriosus; hoarseness of voice; left recurrent laryngeal nerve palsy in adults
23.  Saccular aortic aneurysm that resembled a mediastinal neoplasm 
INTRODUCTION
Saccular aortic arch aneurysms in unusual sites may be misdiagnosed as a neoplasm. We present the case of a rare saccular aortic arch aneurysm between trachea and esophagus that resembled a mediastinal neoplasm in the preoperative findings.
PRESENTATION OF CASE
A 63-year-old male with an abnormal mediastinal shadow on chest X-ray was referred to the hospital. An axial plain computed tomogram of the chest revealed mediastinal soft tissue next to the right side of the aortic arch resembling a neoplasm originating from the gap between the trachea and the esophagus. The coronal view constructed by enhanced 64-row multi detector computed tomography revealed the soft tissue was an aneurysm arising from the inner side of the aortic arch. An aortic arch replacement was performed via a median sternotomy.
DISCUSSION
A thoracic aortic aneurysm sometimes behaves like a mediastinal neoplasm. The multiple cross-sectional image from multidetector computed tomography was useful for the correct diagnosis of such an aneurysm.
CONCLUSION
The possibility of an aneurysm should be considered whenever a mass in contact with the aortic wall is identified.
doi:10.1016/j.ijscr.2012.08.007
PMCID: PMC3484879  PMID: 22995656
Saccular aortic aneurysm; Mediastinal neoplasm; Computed tomography
24.  Technical Challenges in Endovascular Repair of Complex Thoracic Aortic Aneurysms 
Annals of Vascular Diseases  2012;5(1):21-29.
Background: Endovascular aneurysm repair has gained widespread acceptance, and there has been a significant increase in the number of aneurysms treated with stent grafts. However, the endovascular technique alone is often not appropriate for anatomically complex aneurysms involving the neck branches. We used the TAG stent for thoracic aortic aneurysms (TAA), and report our initial results.
Patients and Results: We deployed 80 TAG stents in 65 patients electively treated with TAA between June 2006 and June 2008. Thoracic endovascular aneurysm repair (TEVAR) was performed in 45 cases of descending aortic aneurysm with no morbidity or mortality. A combination of open surgery and TEVAR was performed in 11 out of 20 cases with aneurysms of the aortic arch. The prior total arch replacement and elephant trunk procedure was performed in 3 cases with dilated ascending aorta, total debranching from ascending aorta with sternotomy in 5, and carotid-carotid artery crossover bypass in 3 cases. Meanwhile, TEVAR with coverage of the left subclavian artery was performed in the remaining 9 distal arch cases. In 3 cases with extremely short necks, a 0.018” guide wire was inserted percutaneously in a retrograde manner through the common carotid artery (CCA) into the ascending aorta to place the stent graft in close proximity to the CCA (wire protection). In 1 of these 3 cases, the TAG stent was deployed through the CCA, and the 0.018” guide wire was used to deliver a balloon-expandable stent in order to restore the patency of the CCA. In arch and distal arch aneurysm cases, perioperative mortality and the incidence of stroke were both 5.0%; dissection of the ascending aorta was seen in one case (5.0%).
Conclusion: As treatment for descending aortic aneurysms, TEVAR can replace conventional open repair. However, TEVAR for arch aneurysms has some problems, and further improvement is necessary. (English Translation of Jpn J Vasc Surg 2010; 19: 547-555.)
doi:10.3400/avd.oa.11.01011
PMCID: PMC3595906  PMID: 23555482
Keywordsthoracic aortic aneurysm; endovascular surgery; stent graft
25.  Ortner’s syndrome: a case report and review of the literature 
BMJ Case Reports  2014;2014:bcr2013202900.
We present a case of a 67-year-old man who was an active smoker, with a clinical history of ischaemic cardiopathy, hypertension, who presented to the emergency room with hoarseness of voice of 2 weeks duration. No other neurological or cardiorespiratory symptoms were found. Physical examination revealed an aortic regurgitation murmur with radial pulse difference between the upper limbs and femoral pulse difference on lower limbs. Laryngoscopy examination revealed a left vocal cord paralysis in the paramedian position, without signs of malignancy. Thoracoabdominal CT angiography was performed to rule out an aortic dissection. CT revealed a dissection in the descending thoracic aortic arch and abdominal aorta. Cardiovascular surgery was consulted and decided to place endoprosthesis at the thoracic and abdominal aortic area. Hoarseness eventually resolved during the following weeks. Ortner’s syndrome is described as hoarseness of voice caused by compression of the left recurrent laryngeal nerve of cardiovascular origin.
doi:10.1136/bcr-2013-202900
PMCID: PMC4112344  PMID: 25035442

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