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ICVTS on-line discussion A

University Hospital Sestre Milosrdnice, Zagreb 10000, Croatia

Impact of blood coagulation and fibrinolytic system changes on early and mid term clinical outcome in patients undergoing stent endografting surgery

eComment: The authors stated that EVAR have no clinical relevance and have no effect on early outcome and on mid-term follow-up [1]. At this point, it could be interesting to introduce the condition named penetrating atherosclerotic ulcer [PAU]. In the last 50 months at my institution, 38 patients have undergone EVAR for AAA. A total of 3 patients were found to have an abdominal PAU. In every patient, PAU was diagnosed at computed tomography angiography [CT-A]. Because they were treated electively, it was possible to obtain a histological diagnosis to support the CT diagnosis of PAU. On the basis of histological proofs, the diagnosis of PAU was not assumed but confirmed. PAU is the subject of considerable controversy with respect to definition as well as natural history. In our series, all three patients had distal ischemia caused by embolism, one of them with recurrent embolism that required amputation.

The treatment of PAU remains controversial too. Open surgical repair [OSR] with graft interposition has been used traditionally, but patients with PAU are generally not ideal candidates for OSR because of advanced age and poor general status [2]. As a less invasive treatment for PAU, EVAR was advocated. Early complications after EVAR for abdominal PAU included endoleak mainly; peripheral embolization could be a potential intraoperative complication as well as in the early post-operative course. We opted to use EVAR in order to prevent potential debris migration or fragmentation from the original PAU during positioning or deployment of the device, and to completely exclude the potential aneurysm evolution of the PAU from the systemic flow. Our mid-term morbidity results reveal that deployment of the SGs was successful in all AAA patients, but in none of the PAU patients. Thus, the morbidity data after EVAR for PAU could support a more aggressive approach to this lesion, even in high-risk patients.

A better understanding of the scope of coagulation and fibrinolysis after EVAR could overcome the fear of poor outcome in high risk cases, and for that reason I would like to congratulate the authors.

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1. Monaco M, Di Tommaso L, Stassano P, Smimmo R, De Amicis V, Pantaleo A, Pinna GB, Iannelli G. Impact of blood coagulation and fibrinolytic system changes on early and mid term clinical outcome in patients undergoing stent endografting surgery. Interact CardioVasc Thorac Surg 2006; 5:724–729.[Abstract/Free Full Text]
2. Batt M, Haudebourg P, Planchard PF, Ferrari E, Hassen-Khodja R, Bouillanne PJ. Penetrating atherosclerotic ulcers of the infrarenal aorta: life-threatening lesions. Eur J Vasc Endovasc Surg 2005; 29:35–42.[CrossRef][Medline]

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