Atherosclerotic Vascular Disease Conference
Authors: Michael A. Bettmann, Michael D. Dake, L. Nelson Hopkins, Barry T. Katzen, Christopher J. White, Andrew C. Eisenhauer, William H. Pearce, Kenneth A. Rosenfield, Richard W. Smalling, Thomas A. Sos, Anthony C. Venbrux
Journal: Circulation (2004)

evascularization has changed dramatically over the last 2 decades, with the use of percutaneous interventional techniques both replacing much of what was done with open surgery and increasing the number of patients with noncoronary atherosclerotic disease who are treated.Despite major advances, many questions remain, partly because of the continuing evolution of tools and techniques and partly because of the paucity of large prospective randomized trials.This section reviews recent advances, addresses areas of concern, and focuses primarily on the current status of catheter-based vascular interventions for atherosclerotic vascular diseases. Aortic DiseasesThoracic disease and abdominal aortic disease are distinct yet related disorders.In the context of this discussion, vascular intervention is relevant to thoracic aortic aneurysms (TAAs), dissection and trauma, and abdominal aortic aneurysms (AAAs).Revascularization of aortic occlusive disease is discussed later in conjunction with peripheral artery revascularization.AAAs are far more common than TAAs.The reported incidence depends on the method of surveillance and the specific population, but it is estimated that 5% of men Ͼ65 years of age have small, asymptomatic AAAs.The incidence is greater in men than women, and Ͼ90% of persons with AAA have a long history of tobacco abuse. 1 A more detailed discussion of the etiology and natural history of AAAs is provided elsewhere in this document.The risk of rupture is minimal for aneurysms with a diameter Ͻ4 cm.Conversely, for aneurysms Ͼ6 cm in diameter, the annual rupture risk is Ͼ25%. 2 A rapid increase in size is the best predictor of rupture risk.The conundrum of whom to treat centers on patients with aneurysms in the range of 5 to 5.5 cm.The current status of aortic endografts must be considered in the context of open surgical repair of AAA.Open surgical graft placement has been the standard therapy for AAAs that are 5 to 5.5 cm or larger.Endovascular graft placement for AAA was first reported in 1991.Since then, there has been rapid evolution and use of endovascular grafts for AAA.The focus of development has been making the devices smaller, easier to place, and more durable, effective, and safe.AAA endovascular repair devices are stents connected by graft material, which are implanted superior to an infrarenal AAA and below the distal extension of the aneurysm.This means placing the cephalic-most stent just below or sometimes across the renal arteries and the caudal end in the distal aorta, common iliac arteries, or external iliac arteries, depending on the extent of the aneurysm.If the main renal arteries are covered, the graft material must start just below them, rather than covering the entire cephalic portion of the stent.Newer, low-profile devices can be implanted percutaneously under local anesthesia by use of predelivery sheath placement of percutaneously delivered arterial closure sutures.Once operators have advanced beyond a significant learning curve, early results have shown 95% to 100% success rate in implantation, 1% to 2% 30-day mortality rate, and 0% to 1.5% conversion rate to open repair at the time of placement or by 30 days. 3,46][7] The incidence of endovascular leaks at 1 year ranges from 17% to 31% and may vary among the different devices.Thus, it remains imperative to continue at least annual follow-up with abdominal contrast CT studies toThe opinions expressed in this article are those of the authors and do not necessarily represent those of the editor or the American Heart Association.