ANEURYSMAL DISEASE OF THE THORACIC AND ABDOMINAL AORTA Edited by Marvin D. Atkins and Ruth L. Bush Aneurysmal Disease of the Thoracic and Abdominal Aorta Edited by Marvin D. Atkins and Ruth L. Bush Published by InTech Janeza Trdine 9, 51000 Rijeka, Croatia Copyright © 2011 InTech All chapters are Open Access articles distributed under the Creative Commons Non Commercial Share Alike Attribution 3.0 license, which permits to copy, distribute, transmit, and adapt the work in any medium, so long as the original work is properly cited. After this work has been published by InTech, authors have the right to republish it, in whole or part, in any publication of which they are the author, and to make other personal use of the work. Any republication, referencing or personal use of the work must explicitly identify the original source. Statements and opinions expressed in the chapters are these of the individual contributors and not necessarily those of the editors or publisher. No responsibility is accepted for the accuracy of information contained in the published articles. The publisher assumes no responsibility for any damage or injury to persons or property arising out of the use of any materials, instructions, methods or ideas contained in the book. Publishing Process Manager Mirna Cvijic Technical Editor Teodora Smiljanic Cover Designer Jan Hyrat Image Copyright Blank Michael, 2011. Used under license from Shutterstock.com First published October, 2011 Printed in Croatia A free online edition of this book is available at www.intechopen.com Additional hard copies can be obtained from orders@intechweb.org Aneurysmal Disease of the Thoracic and Abdominal Aorta, Edited by Marvin D. Atkins and Ruth L. Bush p. cm. ISBN 978-953-307-578-5 free online editions of InTech Books and Journals can be found at www.intechopen.com Contents Preface IX Part 1 Evolution of Care for Aortic Disease 1 Chapter 1 The Evidence for Management of Abdominal Aortic Aneurysms: Lessons Learned from Randomised Controlled Trials 3 Reza Mofidi and Stuart A. Suttie Chapter 2 The Evolution of Aortic Aneurysm Repair: Past Lessons and Future Directions 21 Ricky Harminder Bhogal and Richard Downing Chapter 3 Abdominal Aortic Aneurysms: Changing Paradigms in Treatment 55 Christopher J. Marrocco and Ruth L. Bush Part 2 Improvements in the Endovascular and Surgical Management of Aortic Disease 79 Chapter 4 Alternative Surgical Management of Ascending Aorta Aneurysm 81 Sossio Perrotta and Salvatore Lentini Chapter 5 Aortic Valve Sparing Operation 101 Júlia Čanádyová and Aleš Mokráček Chapter 6 Endovascular Repair of Ruptured Abdominal Aortic Aneurysms 121 Cheong J. Lee, Andrew Gonzalez and Mark D. Morasch VI Contents Part 3 Anesthestic and Radiation Management in Aortic Surgery 135 Chapter 7 Ultrasound-Guided Peripheral Nerve Block in the Anesthetic Considerations for Vascular Surgery – An Alternative Choice for Neuroaxial Anesthesia Techniques 137 Yusuke Asakura and Hideki Takagi Chapter 8 Endovascular Repair: Radiation Risks 155 John A. Kalef-Ezra Part 4 Molecular Management in Aortic Disease 191 Chapter 9 Role of Cathepsin K, L and S in Blood Vessel Remodeling 193 Andriy O. Samokhin and Dieter Brömme Chapter 10 Nutrition and the Aorto-Iliac Atherosclerotic Disease 211 Sergio Santana Porbén Preface The first successful open surgical repair of an abdominal aortic aneurysm was in 1951 by Dubost and represented a tremendous milestone in the care of this challenging disease. The introduction of endovascular repair in 1991 by Parodi furthered the care of these patients by allowing for lower morbidity and mortality rates and also, enabling surgeons to extend surgical treatment to patients traditionally deemed too high of a surgical risk. This new book on Aortic Disease covers many interesting and vital topics necessary for both the practicing surgeon as well as a student of vascular disease. The book starts with background information on the evolution of aortic management from traditional open surgical repair to modern endovascular therapies. There is also a chapter covering the data supporting current treatment modalities and how these data have supported modern management. Also, the use of endovascular means for care of the challenging situation of ruptured aneurysms is discussed. In addition to management of abdominal aneurysm, there is a chapter on treatment of aneurysms of the ascending aorta. Along with surgical treatment, one must also understand the molecular basis for how blood vessels remodel and thus, the role of cathepsins in aortic disease is elucidated. Lastly, chapters discussing the perioperative management of radiation exposure and ultrasound-guided nerve blocks as well as the need for high-quality postoperative nutrition will lend well to a full understanding of how to management patients from presentation to hospital discharge. We hope you enjoy this book, its variety of topics, and gain a fuller knowledge of Aneurysmal Disease of the Thoracic and Abdominal Aorta. Marvin D. Atkins, M.D. Assistant Professor of Surgery Scott & White Hospital, Texas A & M College of Medicine, Temple, Texas USA Ruth L. Bush, M.D., M.P.H. Professor of Surgery Scott & White Hospital, Texas A & M College of Medicine, Temple, Texas USA [...]... the aneurysm sac opened and back-bleeding branch arteries (lumbar and inferior mesenteric) are ligated A prosthetic graft, usually made of Dacron, is sutured to the proximal aorta and the aorta proximal to the bifurcation (Figure 3) Fig 3 An orthotopic Dacron graft has been sutured to replace the AAA 26 Aneurysmal Disease of the Thoracic and Abdominal Aorta Demonstrates the satisfactory position of. .. virtual elimination of the possibility of endoleaks associated with EVAR (see below) In addition, open AAA repair offers complete treatment of aneurysmal disease with obliteration of the aneurysmal sac and debridement of its clot and atheromatous debris and most importantly is of proven durability Of all the technical advantages of open repair, secure fixation at all anastomoses is probably the most important... good with 4 Aneurysmal Disease of the Thoracic and Abdominal Aorta the other three trials classified as fair i.e not meeting all the criteria but judged to have no fatal flaws7 The Chichester trial was the first to assess the value of screening for AAA in the at risk population It was also unique as it included women as well as men It identified all men and women aged between 65 and 80 years of age from... 5.5-6.0 cm and is the primary indication for the repair of both TAA and AAA Therefore surgery to repair both AAA and TAA is either pre-emptive to prevent rupture or emergent to repair a rupture Repair of TAA and AAA by either open or minimally invasive techniques significantly reduces the risk of rupture and improves patient mortality The establishment of these techniques has required the development of procedures... surgeon Rudolph Matas renovated the approach of Antyllus and Aëtius of Amida and carried out endoaneurysmal ligature of peripheral aneurysms The approach spared collaterals around the aneurysmal sac Matas also first proposed the concept of endoaneurysmorrhaphy and performed the first successful aortic ligation on a human The Canadian physician William Osler called him the ‘Father of Vascular Surgery’ but... statin therapy over a 2 year follow up period61 Schlosser et al in an analysis of the results of a large observational cohort study which 14 Aneurysmal Disease of the Thoracic and Abdominal Aorta involved 5057 patients with vascular disease (Second Manifestation of ARTerial disease (SMART) study) and included 230 patients with small AAA revealed an independent association between statin therapy and reduced... all the other measures which have helped to optimise therapeutic strategies in the management of patients with AAA throughout the patients’ journey from the initial diagnosis to the eventual repair of AAA 2 Targeted screening for AAA In the past 40 years with the advent and generalised use of abdominal ultrasonography there has been an accurate, cheap and non invasive tool for the diagnosis of abdominal. .. mortality from AAA in the patient population is reported to be between 1.1 to 3-percent18 6 Aneurysmal Disease of the Thoracic and Abdominal Aorta Takagi et al conducted a further meta-analysis of US screening in the male population over the age of 65years using long term 10 to 15 year follow up data from the RCTs They reported an absolute risk reduction in aneurysm related mortality of 4 per 1000 subjects... techniques of both open and minimally invasive aortic aneurysm repair 3 Open repair of abdominal aortic aneurysm 3.1 Open AAA repair The advances dating from Antyllus through to Oscar Creech led to the development of a standard operative procedure to repair AAA More recently, non-invasive screening 24 Aneurysmal Disease of the Thoracic and Abdominal Aorta programs and a dramatic rise in the elderly population... appearance of a fusiform AAA as seen on transverse CT The aneurysm contains thrombus with radio-contrast seen within the lumen CT defines the aneurysm in terms of morphology, either fusiform or saccular, but more importantly defines the anatomy of the aneurysm neck Ninety five per cent of AAA are infra-renal, ie the neck of the aneurysm originates below the origin of the renal arteries and thus aneurysm . ANEURYSMAL DISEASE OF THE THORACIC AND ABDOMINAL AORTA Edited by Marvin D. Atkins and Ruth L. Bush Aneurysmal Disease of the Thoracic and Abdominal Aorta. this book, its variety of topics, and gain a fuller knowledge of Aneurysmal Disease of the Thoracic and Abdominal Aorta. Marvin D. Atkins, M.D. Assistant Professor of Surgery Scott &. Using the predefined criteria set by the US Preventative Screening Task Force USPSTF 6 the MASS trial has been classified as good with Aneurysmal Disease of the Thoracic and Abdominal Aorta