Regarding "Laparoscopic remodeling of abdominal aortic aneurysms after endovascular exclusion: a technical description".

The injury and destruction of normal healthy tissue to achieve repair of diseased tissue is the great anathema of surgery. This is a prominent feature of open aortic aneurysm resection. Whether performed through a midline abdominal incision or a retroperitoneal approach, the conduct of the procedure is similar, with division of soft tissues, retraction of the intestines for a significant period of time, the placement of vascular clamps, and the suture repair of these tissues. Numerous physiologic alterations occur that are virtually coincident with surgical tissue injury and proportional to its extent. The consequences of these alterations are well known and may affect outcomes. Concentrations of circulating neuroendocrine mediators rise significantly and remain elevated for a prolonged period of time after the procedure. Nearly a decade ago, Riles and associates documented rapid elevations in plasma epinephrine and norepinephrine levels during open aneurysm resection and suggested a link between these stress mediators and postoperative myocardial ischemia. This link between the neuroendocrine response to surgery and postoperative myocardial ischemia has been confirmed by others, strengthening the relationship between tissue injury and adverse outcome. Long-term outcome may also be affected. White and colleagues noted a 5-year survival rate in patients aged 60 to 70 years undergoing open aneurysm resection of 67% compared with that of 88% in age-matched controls. Aune and associates noted a 10-year survival rate of patients undergoing aneurysm resection of 38% compared with 52% for the matched controls. The majority of deaths are cardiac in origin and strongly argue for the development of alternative methods of aneurysm repair that are more specific and associated with minimal tissue destruction. It is well recognized that the treatment of vascular disease through percutaneous procedures is associated with less tissue trauma. There is a lower rate of postintervention myocardial infarction compared with open surgery, and this may also result in a long-term cardiac benefit. Reviewing the results of the Veterans Affairs study comparing angioplasty with surgery for the treatment of superior femoral artery disease, Bergan and colleagues noted a sustained reduction in cardiac deaths in those treated percutaneously compared with those treated with femoropopliteal bypass. The impact of such results has been limited because balloon angioplasty as a treatment for lower extremity arterial occlusive disease generally does not provide the same degree or durability of circulatory improvement as open bypass procedures. The same indictment cannot be applied to aortic stent graft placement. This technology, when appropriately applied, effectively excludes an aortic aneurysm and significantly reduces the likelihood of associated complications. Additionally, there has been a growing body of data regarding a reduction of the neuroendocrine response associated with this form of aneurysm repair. In a study of 10 patients undergoing aortic stent grafts compared with 10 patients having open aneurysm resection, Salartash and colleagues measured epinephrine, cortisol, insulin, and retinol-binding protein levels before, during, and after intervention. Peak epinephrine levels rose 1.6-fold in the stent graft group compared with a 9.6-fold increase in the open resection group. Thompson and associates documented greater rises in plasma catecholamine concentrations, more significant changes in cardiovascular parameters, and greater alterations in acid-base status in patients undergoing open aneurysm resection compared with those having aortic stent graft placement. Such studies, while few, suggest that these reductions in stress mediators may result in a decreased cardiac mortality and support the use of aortic stent grafts. Despite the promise of improved long-term outcomes, however, these new technologies are not without attendant complications. After more than a decade of development, application, and evaluation of these devices, unpredicted shortcomings are still being discovered. Fabric holes, degradation of the metal exoskeleton or fixation sites, enFrom the Department of Surgery, Advocate-Lutheran General Hospital. Competition of interest: nil. Reprint requests: John V. White, MD, Lutheran General Hospital, Department of Surgery, 1775 Dempster St, Park Ridge, IL 60068-1174. J Vasc Surg 2002;36:1271-3. Copyright © 2002 by The Society for Vascular Surgery and The American Association for Vascular Surgery. 0741-5214/2002/$35.00 0 24/9/129489 doi:10.1067/mva.2002. 129489