Can Intrasac Pressure Monitoring Reliably Predict Failure of Endovascular Aneurysm Repair?

Purpose: To determine if pressure measured at a single location within aneurysm sac thrombus accurately reflects the force applied to the aneurysm wall and the risk of rupture by examining (1) if pressure is distributed uniformly within aneurysm thrombus, (2) the pressure transmission through aneurysm thrombus, and (3) the microstructural basis for pressure transmission. Methods: Pressure within aneurysm thrombus was measured by direct puncture through the aneurysm wall at 121 sites in 26 patients during open abdominal aortic aneurysm repair. Measurements were taken prior to cross clamping and compared with intrasac pressure measured at 30 sites in 6 patients without aneurysm thrombus (controls). Transmission of pressure through aneurysm thrombus was further examined ex vivo by subjecting fresh thrombus to a pressure gradient in a custom-made pressure cell. Pressure transmission was correlated with matrix density as determined by light microscopy and image analysis. Results: Mean pressure within aneurysm thrombus was higher than mean systemic pressure in 11 patients, lower in 1, and identical in 9. In 5 patients, the pressure was greater than systemic in some areas of the thrombus but less in others. Sac pressure was identical to systemic pressure at all sites in the controls. In 12 thrombus specimens (6 patients) examined in the pressure cell, pressure transmission varied significantly between specimens, correlating directly with matrix density ( R 2 =0.747, p=0.001). Conclusions: Pressure transmission through aneurysm thrombus is variable and depends upon the microstructure of the thrombus. Pressure measured at a single location may not, therefore, accurately reflect the pressure acting on the aneurysm wall.