Abdominal Aortoiliac Aneurysms Research Articles

The Enzen Trial: Analysis of EVAR Endoprosthesis Zenith and Endurant for Infrarenal Aortoiliac Aneurysms Regarding Outcomes, Endoleaks, and Reinterventions.

The main objective of this paper is to analyze the outcomes regarding endoleaks, reinterventions, and death related to aneurysm complications in patients submitted to endovascular repair (EVAR) for abdominal aortoiliac aneurysm (AAA) using Endurant II (Medtronic) and Zenith Flex (Cook) endografts. This was a prospective, consecutive cohort study of patients with AAA who underwent EVAR between January 2019 and December 2022. Two groups of patients were evaluated: Group Endurant (patients submitted to EVAR with the use of Endurant II) and Group Zenith (patients submitted to EVAR with the use of Zenith Flex). A total of 156 patients were evaluated. Group Zenith (67 patients, 42.9%) and Group Endurant (89 patients, 57.1%). The perioperative mortality was 5.1%, eight patients (six patients Group Zenith, and two patients Group Endurant, p=0.054). There were 28 patients (17.9%) submitted to urgent repair of the aneurysm (expansion or rupture), with no differences among the groups. There were 36 cases (23.1%) of later endoleak, with a higher incidence in Zenith group (23 patients, 34.3%) than Endurant group (13 patients, 14.6%, p=0.002), most of them Type II endoleak (21 patients, 13.4%). There were 12 cases of Type I endoleak, also with a higher prevalence in Zenith group (13.4%) than Endurant group (3.4%, p=0.002). Moreover, regarding limb graft occlusion (LGO), there were nine patients (5.8%), with a higher prevalence in Zenith group (9%) than Endurant group (3.4%, p=0.045). The overall survival in a Kaplan-Meier at 720 days was 82.3% in the Zenith group and 89.1% in the Endurant group, with no statistical significance among the groups (p=0.09). The freedom from reintervention rates in a Kaplan-Meier at 720 days was 82.8% in the Zenith group and 93.2% in the Endurant group (p=0.001). In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, LGO and reinterventions than patients submitted to Endurant II endografts. The linear regression analysis showed that the presence of endoleaks, type of endograft device (Zenith graft) and limb graft occlusion were related to higher reintervention rates. In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, limb graft occlusions and reinterventions than patients submitted to Endurant II endografts. The main impact and the innovation that this article provides is an opportunity to evaluate and choose the best endograft suitable for the patient with AAA during EVAR.

Arteriovenous Fistula Caused by Ruptured Abdominal Aortoiliac Aneurysm.

Teaching point: A ruptured aorto-iliac aneurysm, complicated by an iliac arteriovenous fistula, is rare but has a possibly fatal outcome and requires prompt diagnosis and appropriate treatment.

Endovascular repair for infra-renal aortic aneurysms with supra-renal fixation endoprosthesis: Results and outcomes.

The main objective of this paper is to evaluate the outcomes regarding endoleaks, reinterventions, and death related to aneurysm complications in patients submitted to endovascular repair (EVAR) for abdominal aortoiliac aneurysm (AAA) using Endurant II (Medtronic) and Zenith Flex (Cook) endografts. This was a prospective, consecutive cohort study of patients with AAA who underwent EVAR with the use of Endurant II stent graft and Zenith Flex endograft. A total of 156 patients submitted to EVAR were evaluated. The perioperative mortality was 5.1%, 8 patients. The median clinical follow-up period was 760 ± 80 days. There were 28 patients (17.9%) submitted to urgent repair of the aneurysm (symptomatic expansion or rupture) and 128 patients (82.1%) submitted to elective repair. There were 36 cases (23.1%) of later endoleak and most of them are Type II endoleaks (21 patients, 13.4%). There were 12 cases of Type I endoleak. Moreover, regarding limb graft occlusion (LGO), there were 9 patients (5.8%). The overall survival rate in Kaplan-Meier analysis at 720 days was 84.8% in the total cohort. The freedom from reintervention rate in Kaplan-Meier analysis at 720 days was 92.7% in the total cohort. The linear regression analysis for survival rates showed that chronic kidney disease (p = .03; hazard ratio (HR) = 2.82, CI = 1.07-4.44) was the only factor related to poorer survival rates in both univariate and multivariate analyses. The linear regression analysis showed that the presence of endoleaks (p < .001, HR = 6.69, CI = 2.26-8.48) and limb graft occlusion (p < .001, HR = 8.02, CI = 1.60-9.99) were related to reintervention in both univariate and multivariate analyses. In this present study, supra-renal fixation endograft devices were safe and efficient in treating AAA, with satisfactory results and no renal compromise. The linear regression analysis showed that the presence of endoleaks and limb graft occlusion were related to higher reintervention rates in both univariate and multivariate analyses.

Navigating Challenges in the Endovascular Treatment of Asymptomatic Aortoiliac Aneurysms: A 10-Year Comparative Analysis.

Treating an abdominal aortoiliac aneurysm (AAIA) with endovascular methods can be challenging when the internal iliac artery (IIA) is involved. Embolizing the IIA and extending the limb to the external iliac artery (IIAE + EE) to prevent a type 2 endoleak may lead to pelvic ischemic complications. To avoid these complications, strategies that preserve the IIA, such as the bell-bottom technique (BBT) and the iliac branch device (IBD), have been proposed. This study aims to compare the outcomes of these three endovascular approaches for AAIA. Between January 2010 and December 2019, 174 patients with asymptomatic AAIA were enrolled in this retrospective analysis. They were divided into two groups: 81 patients underwent non-IIAE procedures, and 93 patients underwent IIAE procedures. The iliac limb study group consisted of 106 limbs treated with the BBT, 113 limbs treated with the IIAE + EE, and 32 limbs treated with the IBD. The primary outcomes included the 30-day mortality rate and intraoperative limb complications. The secondary outcomes included postoperative pelvic ischemia, freedom from reintervention, and the overall 10-year survival rate. There was no significant difference in the perioperative mortality rate between the non-IIAE group (0%) and the IIAE group (2.1%), p = 0.500. The intraoperative limb complications did not differ significantly between the BBT limbs (7.5%), the IIAE + EE limbs (3.5%), and the IBD limbs (3.1%) groups, p = 0.349. The incidence of buttock claudication was significantly greater in the bilateral IIAE + EE group compared to the unilateral IIAE + EE and non-IIAE groups (25%, 11%, and 2.5%, p-value < 0.004), and was similar to the incidence of buttock rest pain with skin necrosis (15%, 0%, and 0%, p < 0.001). During the 10-year follow-up, the BBT limbs group had a significantly lower rate of iliac limb reintervention free time than the IIAE + EE limbs and the IBD limbs groups (88.7%, 98.2%, and 93.8%, p = 0.016). There was no significant difference in the overall 10-year survival rate between the non-IIAE and IIAE groups (51.4% vs. 55.9%, p = 0.703). The early and late mortality rates were similar between the non-IIAE and IIAE groups. Preserving the IIA is recommended to avoid pelvic ischemic complications. Considering the higher rate of reintervention in the BBT group, the IBD strategy may be preferred for AAIA.

Mid-Term Outcomes of a Pre-Cannulated Iliac Branched Device in the Treatment of Abdominal Aortoiliac Aneurysms: A Retrospective Analysis from a Single Center.

The aim was to assess the mid-term results of the E-iliac branched device. Baseline and follow-up data of this monocentric retrospective cohort study including all consecutive patients with aortoiliac aneurysms treated with iliac branched devices between 2016 and 2023 were extracted from the hospital records. Preoperative and follow-up CT scans were analyzed regarding endoleaks, migration, aneurysm sac remodeling, and device patency. Overall, 50 devices were implanted in 38 patients with a median age of 69 (IQR 62-78) years, and 1.6 bridging stent grafts per vessel were implanted through transfemoral (22/50; 44%) or upper extremity access (28/50; 56%). Primary technical success and assisted technical success were 97% (37/38) and 100% (38/38), respectively. No migration, no type I or III endoleaks, no stroke, colonic ischemia, aneurysm rupture, or conversion during the early and mid-term follow-ups (11 months, IQR 5-26) were observed. Aneurysm sac enlargement or shrinkage was observed in 0% (0/38) and 16% (6/38) patients, respectively. E-iliac-related re-interventions were seen only during the early follow-up: two thrombectomies with bare-metal stent relining after thrombosis of the iliac limb. Bridging stent graft and E-iliac patency during the mid-term follow-up were 100%. E-iliac showed encouraging mid-term results in the treatment of aortoiliac aneurysms with high technical success and a low re-intervention rate.

Incisional Hernias after Vascular Surgery for Aortoiliac Aneurysm and Aortoiliac Occlusive Arterial Disease: Has Prophylactic Mesh Changed This Scenario?

Incisional hernia (IH) is an important surgical complication that has several ways of prevention, including modifications in the surgical technique of the initial procedure. Its incidence can reach 69% in high-risk patients and long-term follow-up. Of the risky procedures, open abdominal aortic aneurysmectomy is the one with the highest risk. Ways to reduce this morbid complication were suggested, and prophylactic mesh rises as an important tool to prevent recurrence. A retrospective cohort study review of medical records of patients undergoing vascular surgery for abdominal aortoiliac aneurysm (AAA) or vascular bypass surgery due to aortoiliac occlusive disease. We identified 193 patients treated between 2010 and 2020. We further performed a one-to-nine matching analysis between the use of prophylactic mesh and control groups, based on estimated propensity scores for each patient. Prophylactic mesh group had a 18% lower risk of IH, compared with the control group (relative risk: 0.82; 95% confidence interval [CI] = 0.74-0.93). The difference in IH rates between the groups compared was 2.6% (95% CI: -19.8 to 25.5). From the perspective of the number needed to treat, it would be necessary to use prophylactic mesh in 39 (95% CI: 35-44) patients to avoid one IH in this population. Use of prophylactic mesh in the repair of AAA significantly reduces the incidence of IH in nearly one in five cases. Our data suggest that there is benefit in the use of prophylactic mesh in open aneurysmectomy surgery regarding postoperative IH development.

Your New Year’s “resolution”—check your “screen!”

Your New Year’s “resolution”—check your “screen!”

Stratified Endovascular Aneurysm Repair Follow Up Is No Longer Utopia But Remains Undefined

Despite ongoing discussion, the optimal strategy for endovascular aneurysm repair (EVAR) follow up is undetermined, mostly because of an absence of level I evidence. Two concepts, however, are now quite evident: some degree of imaging surveillance is necessary for all patients; and stratification of intensity and image modality is appropriate to improve the efficiency of follow up and minimise its shortcomings. With these prerogatives in mind, Kirkham et al.1 sought to validate the EVAR follow up scheme proposed by the 2019 European Society for Vascular Surgery (ESVS) Clinical Practice Guidelines on abdominal aorto-iliac artery aneurysm (AAA) management.

Did Percutaneous Compared with Cutdown Access for Endovascular Aneurysm Repair Really Make a Difference?

Did Percutaneous Compared with Cutdown Access for Endovascular Aneurysm Repair Really Make a Difference?

Contemporary Analysis of Senior Level Case Volume Variation Between Traditional Vascular Surgery Fellows and Integrated Vascular Surgery Chief Residents

A review was performed of Accreditation Council for Graduate Medical Education integrated vascular surgery, vascular surgery fellowship, and general surgery case logs for trainees graduating between 2013 and 2018. The 5+2 trainees performed a significantly greater mean volume of vascular cases compared with the 0+5 trainees by the time they had completed training. These included open repair of suprarenal aortic aneurysms (2.4 vs 1.4), thoracic aortic aneurysms (0.5 vs 0.3), endovascular repair of abdominal aortoiliac aneurysms (45 vs 28), thoracic aortic aneurysms (TEVAR; 15 vs 8), femoral-popliteal (10 vs 6) and infrapopliteal (14 vs 9) vein bypasses, carotid artery endarterectomy (47 vs 29), carotid artery stenting (10 vs 5), celiac/superior mesenteric artery endarterectomy or bypass (4 vs 2), renal artery balloon angioplasty/stenting (5 vs 3), thoracic outlet decompression (5 vs 2), arteriovenous fistulas (31 vs 16), and arteriovenous grafts (11 vs 5). The 5+2 trainees logged significantly more “senior” vascular cases than did the 0+5 trainees.

Predictors of Operative Mortality of 928 Intact Aortoiliac Aneurysms

The aim of this study is to identify preoperative and intraoperative factors associated with in-hospital mortality of intact abdominal aortoiliac aneurysm repair. In this observational study, prospectively collected information included demographics, risk factors, comorbidities, aneurysm characteristics (including special aneurysm presentation, i.e., inflammatory, mycotic/infected, aortocaval fistula), investigations, and operative variables. Receiver operating characteristic) curve analysis of the Glasgow aneurysm score (GAS) and the Vascular Study Group of New England (VSGNE) score was performed in the subgroup of bland aneurysms undergoing isolated elective repair. A total of 928 cases with intact aortoiliac aneurysms had an elective (n=882) or urgent (n=46) repair, associated with an in-hospital mortality of 1.7% and 8.7%, respectively (P=0.01). Open repair (n=514) was a predictor of higher mortality (3.3% vs. 0.5% for endovascular aneurysm repair [EVAR], n=414, odds ratio [OR] 7.1, P=0.003), and so was the pre-EVAR era (4.8% vs. 1.3% in the EVAR era, OR 4.0, P=0.004). Other significant predictors included the presence of abdominal/back pain (7.5% vs. 1.3%, OR=6.0, P=0.001), preoperative angiography (7% vs. 1.6%, OR=4.5, P=0.01), special aneurysm presentation (10.9% vs. 1.5%, OR=8.1, P<0.001), concomitant major procedures (19% vs. 1.7%, OR=14.0, P<0.001), serious intraoperative complications (9.1% vs. 1.5%, OR=6.6, P=0.001), median number of transfused units of blood intraoperatively (2 and 0 for cases with and without mortality, respectively, P<0.001), and procedure duration (270 and 150min for cases with and without mortality, respectively, P<0.001). Open repair (OR=4.5, P=0.05), special aneurysm presentation (OR=6.58, P=0.001), and concomitant major procedures (OR=14.3, P<0.001) were independent predictors of higher mortality. ROC curve analysis for the GAS (P=0.87) and VSGNE score (P=0.10) failed to demonstrate statistical significance in the subgroup of bland aneurysms undergoing isolated elective repair. Our study has demonstrated independent risk factors for mortality, which should be considered when contemplating aortoiliac aneurysm repair. We failed to externally validate the GAS and VSGNE score.

A new randomized controlled trial on abdominal aortic aneurysm repair is needed

Guidelines from societies are based on selected literature and scientific evidence preferably derived from randomized controlled trials (RCTs). Recent Society for Vascular Surgery guidelines 1 Chaikof E.L. Dalman R.L. Eskandari M.K. Jackson B. Lee W.A. Mansour A. et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018; 67: 2-77.e2 Abstract Full Text Full Text PDF PubMed Scopus (957) Google Scholar on the care of patients with abdominal aortic aneurysm (AAA) recommend an assessment of operative risk and life expectancy in contemplating open repair or endovascular aneurysm repair (EVAR) using the patients' Vascular Quality Initiative perioperative mortality risk score (level 2, evidence C). The European Society for Vascular Surgery guidelines 2 Wanhainen A. Verzini F. Van Herzeele I. Allaire E. Bown M. Cohnert T. et al. European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. 2019; 57 ([published correction appears in Eur J Vasc Endovasc Surg 2020;59:494]): 8-93 Abstract Full Text Full Text PDF PubMed Scopus (957) Google Scholar recommend that in most patients with suitable anatomy and reasonable life expectancy, EVAR should be considered the preferred treatment modality (recommendation 60, class IIa; evidence level B). However, in patients with long life expectancy, these guidelines recommend that open surgical repair (OSR) of AAA should be considered the preferred treatment modality (recommendation 61, class IIa, evidence level B). These recommendations are based on previous RCTs comparing OSR with EVAR for AAA. 3 EVAR Trial ParticipantsEndovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet. 2005; 365: 2179-2186 Abstract Full Text Full Text PDF PubMed Scopus (1314) Google Scholar , 4 Prinssen M. Verhoeven E.L. Buth J. Cuypers P.W. van Sambeek M.R. Balm R. et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004; 351: 1607-1618 Crossref PubMed Scopus (1634) Google Scholar , 5 Becquemin J.P. The ACE trial: a randomized comparison of open versus endovascular repair in good risk patients with abdominal aortic aneurysm. J Vasc Surg. 2009; 50: 222-224 Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar , 6 Lederle F.A. Freischlag J.A. Kyriakides T.C. Padberg Jr., F.T. Matsumura J.S. Kohler T.R. et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009; 302: 1535-1542 Crossref PubMed Scopus (837) Google Scholar New randomized controlled trials for abdominal aortic aneurysm treatment should focus on younger, good-risk patientsJournal of Vascular SurgeryVol. 73Issue 6PreviewIn their editorial, Spanos et al1 concluded that new randomized controlled trials (RCTs) are needed to compare endovascular aneurysm repair (EVAR) with open surgical repair (OSR). They observed that current surgical society guidelines depend on outdated RCTs showing perioperative superiority for EVAR that is lost during the long-term follow-up period. The shortcomings of those trials included the learning curve in the early days of EVAR, evolving approaches to reintervention, and advances in technology leading to improvements in EVAR durability. Full-Text PDF

Contemporary Analysis of Senior Level Case Volume Variation between Traditional Vascular Surgery Fellows and Integrated Vascular Surgery Chief Residents

The present study compares the senior level operative experience of graduates from the traditional vascular surgery fellowship (5+2) and integrated vascular surgery training programs (0+5) using contemporary operative case log data. The Accreditation Council for Graduate Medical Education integrated vascular surgery, vascular surgery fellowship, and general surgery case logs for trainees graduating between 2013 and 2018 were queried for vascular surgery procedures. "Senior" cases were categorized as cases logged as "surgeon fellow" by 5+2 trainees or "surgeon chief" (post graduate year-4,5) by 0+5 trainees. Overall case volume was defined as the combined volume of cases logged as "surgeon junior," "surgeon chief," "surgeon fellow," "teach assist," "first assist," or "secondary procedure." To reflect total vascular experience, all vascular cases done during general surgery residency were combined with cases performed during vascular surgery fellowship. Mean case volumes were compared for all operations/procedures. The 5+2 trainees had higher mean volume of open repair of suprarenal aortic aneurysms (2.4 vs. 1.4, P=0.0026) and open repair of thoracic aortic aneurysms (0.5 vs. 0.3, P=0.004) at the fellow level compared to 0+5 surgeon chief cases. Additionally, 5+2 trainees performed more endovascular repair of abdominal aortoiliac aneurysm (44.7 vs. 28.4, P<0.0001), endovascular repair of iliac artery aneurysm (1.9 vs. 1.2, P=0.0003), and endovascular repair of thoracic aortic aneurysm (14.9 vs. 8.4, P<0.0001). The 5+2 fellows performed more vein bypasses than 0+5 chief residents (femoral-popliteal 9.8 vs. 6.4, P=0.002; infrapopliteal 13.9 vs. 8.8, P=0.0490), extra-anatomic bypasses (axillofemoral 4.2 vs. 2.9, P=0.0004; femoral-femoral 5.6 vs. 3.1, P=0.034), carotid endarterectomies (47.3 vs. 29.3, P<0.0001), carotid artery stenting (9.6 vs. 4.5, P=0.0001), celiac/SMA endarterectomy or bypass (3.7 vs. 1.9, P<0.0001), renal artery balloon angioplasty/stenting (5.0 vs. 2.5, P=0.0006), thoracic outlet decompression (5.4 vs. 1.9, P<0.0001), traumatic repairs [thoracic vessels (0.5 vs. 0.1, P<0.0001), neck vessels (0.7 vs. 0.3, P=0.0004), abdominal vessels (3.0 vs. 1.7, P=0.0005), and peripheral vessels (6.6 vs. 3.1, P=0.034)], as well as a higher mean volume of arteriovenous (AV) fistulas (30.7 vs. 15.7, P<0.0001), AV grafts (10.7 vs. 5.1, P<0.0001), and revision of AV access (16.1 vs. 8.0, P=0.0003). Although both pathways graduate trainees with a similar overall surgical experience, 5+2 trainees log significantly more "Senior" cases. Further studies investigating potential variation in operative autonomy between both pathways are necessary.

The outcomes of internal iliac artery preservation during endovascular or open surgery treatment for aortoiliac aneurysms

BackgroundInternal iliac artery (IIA) preservation continues to be a challenge during open surgery or endovascular repair of abdominal aortoiliac aneurysm (AAIA).ObjectivesTo determine the results in terms of survival and clinical outcomes in patients with aortoiliac aneurysms (AAIA) treated with endovascular (EV) or open surgical (OS) repair.MethodsThis was a retrospective consecutive cohort study of patients with AAIA who underwent EV or OS repair.ResultsPost-procedure hospitalization time and intensive care unit stay were both longer in the OS group than in the EV group (7.08 ± 3.5 days vs. 3.32 ± 2.3 days; p = 0.03; 3.35 ± 2.2 days vs. 1.2 ± 0.8 days; p = 0.02, respectively). There were two cases of bowel ischemia (4.7%; OS 8.3% and EV 3.2%; p = 0.48), two cases of buttock claudication (4.7%; OS 8.3% and EV 3.2%; p = 0.48), and one case of sexual dysfunction (2.3% OS), all of them in patients with bilateral occlusion of the internal iliac artery (five patients, 11.6%; p = 0.035). Overall survival at 720 days was 80.6% in the EV group and 66.7% in the OS group (p = 0.58).ConclusionsIn the present study, OS and EV repair of aortoiliac aneurysms had similar overall survival and outcomes. Preservation of at least one internal iliac artery is associated with good results and no further complications.

The most important news in the new ESVS 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysm.

The "new" and updated European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysm, published in the 2019 January issue of the European Journal of Vascular and Endovascular Surgery, is an extensive document offering 125 recommendations of clinical importance on the management of AAA, accompanied by a comprehensive supporting text that summarizes the literature and motivates the positions made. Several new topics, not addressed in the previous guidelines, are included. Here we summarize the most important news in the new ESVS 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysm.

Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms

Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms

Virtual Monochromatic Dual-Energy Aortoiliac CT Angiography With Reduced Iodine Dose: A Prospective Randomized Study.

The purpose of this study was to assess the feasibility of performing abdominopelvic aortoiliac CT angiography (CTA) with 16.0 g of iodine contrast medium acquired with low-energy (40 and 50 keV) virtual monochromatic (VMC) images with rapid-kilovoltage-switching dual-energy CT. A total of 52 adults with abdominal aortoiliac aneurysm and prior 120-kVp single-energy CTA (SECTA) with 33 g iodine (standard dose) underwent follow-up dual-energy CTA (DECTA) with a 52% reduced iodine dose. Subjects were randomly assigned to a contrast medium protocol for DECTA examinations: one group (n = 26) received 16.2 g (270 mg I/mL) and the other (n = 26) received 16.0 g (320 mg I/mL). Two readers independently assessed SECTA and VMC DECTA datasets for image quality using a 5-point scale. Aortoiliac intravascular attenuation was measured, and ANOVA was used to compare measurements between VMC DECTA and SECTA images. In a subset of patients with DECTA after endovascular aortic repair, endoleak detection was evaluated on VMC images. Volume CT dose index, dose-length product, and size-specific dose estimate were compared between DECTA and SECTA. All DECTA examinations (n = 52) were rated diagnostic with image quality scores comparable to those of 120-kVp single-energy CTA (40 keV, 4.2-4.4; 50 keV, 4.6-4.8; SECTA, 4.4-4.5). Intravascular attenuation was uniform in all reduced-iodine DECTA examinations and was significantly higher on 40- and 50-keV images than on standard-iodine-dose SECTA images (720 ± 125 HU and 482 ± 82 HU vs 303 ± 65 HU) (p < 0.01). There was no difference in intravascular attenuation between the 16.2-g and the 16.0-g doses (p = 0.82). Sensitivity and specificity for endoleak detection were 78.9-94.7% and 100%. Total dose-length product was lower for DECTA (788 ± 166 mGy · cm) than for SECTA (1114 ± 468 mGy · cm). Low-energy VMC DECTA images (40 and 50 keV) acquired with two contrast protocols at approximately 50% reduced iodine dose (16.0 and 16.2 g) provide adequate intravascular attenuation and diagnostic quality for aortoiliac evaluation.

Outcome after Interruption or Preservation of Internal Iliac Artery Flow During Endovascular Repair of Abdominal Aorto-iliac Aneurysms

Outcome after Interruption or Preservation of Internal Iliac Artery Flow During Endovascular Repair of Abdominal Aorto-iliac Aneurysms

Complex EVAR for abdominal aorto-iliac aneurysm (AAIA) is associated with high rate of endoleak and less aortic sac shrinkage compared to conventional EVAR for AAA.

Endovascular repair (EVAR) for large abdominal aortic aneurysm (AAA) in anatomically suitable patients is associated with low early mortality and morbidity. However, EVAR is associated with a significant risk of late complication and a high cumulative re-intervention rate. Many large experienced centres have offered complex EVAR to challenging aortic anatomies such as abdominal aorto-iliac aneurysm (AAIA). We hypothesised that complex EVAR, for AAIA, would be associated with an increased risk of late graft-related complications. The design was a Retrospective Clinical Cohort Study. From a prospective computerised database we identified consecutive patients undergoing EVAR in a single institution between 2008 and 2009. We retrieved analysis clinical data and digital Computed Tomographic Angiography (CTA) scans carried out pre-, early post-, and late post-EVAR. We compared patients undergoing complex EVAR for AAIA with those undergoing conventional standard EVAR for AAA. We identified 93 consecutive patients undergoing EVAR, 13 patients were excluded (3 eEVAR, 1 TEVAR, 9 data could not be retrieved) leaving 80 patients for analysis, 63 male and 17 female, average age 74.5 years (range 57-86), average follow-up 38 months (range 27-50), primary EVAR success was 100% and there was no mortality. Complex EVAR, EVAR plus internal iliac artery embolisation (+IIAE) and extension of the ipsilateral graft limb to the external iliac artery, for AAIA were carried out in 19/80 patients. After standard EVAR, late post-EVAR AAA sac diameter was significantly reduced in EVAR (63.24 ± 9.76 vs 54.26 ± 13.70, p < 0.001) but not after complex EVAR+IIAE (58.89 ± 16.39 vs 52.35 ± 12.75, p = 0.62). Endoleak these were significantly more common in the complex EVAR+IIAE, 5/19 (26.32%), as compared to the standard EVAR, 11/61 (18.03%), p < 0.01. Interestingly, inferior mesenteric artery (IMA) Patency was much commoner after complex EVAR+IIAE (15/19, 78.95%) compared EVAR (29/61, 47.54%), p < 0.01. EVAR can be carried out with low early mortality but has a significant risk of late complication, the commonest of which is endoleak. Complex EVAR for abdominal aorto-iliac aneurysm can be carried out with comparable results to conventional EVAR. However, high rates of persistent endoleak and inferior mesenteric artery patency, and lack of aneurysm sac shrinkage, would suggest they may be at increased risk of late complications and may benefit from enhanced and extended radiological surveillance.

Aortoiliac aneurysm with congenital right pelvic kidney

The association of congenital pelvic kidney with abdominal aortoiliac aneurysm is an extremely rare clinical finding. Previous reports have described various methods of aneurysm repair with successful preservation of the function of pelvic kidney. However, to our knowledge, reconstruction of more than two renal arteries has not been established. We report a case of abdominal aortic aneurysm complicated by congenital right pelvic kidney in a 72-year-old man. Computed tomography (CT) revealed an abdominal aortic aneurysm with a maximum diameter of 54mm and a right common iliac aneurysm of 45mm. In addition, he had a congenital right pelvic kidney and CT angiography identified three right pelvic renal arteries. The upper artery originated from the bifurcation of the terminal aorta and the lower two originated from the right common iliac artery. Three-dimensional CT was helpful for the accurate planning of the operation. Open surgical repair of the aortoiliac aneurysm with a Dacron bifurcated graft replacement was decided and reimplantation of all three right pelvic kidney arteries to the right limb of the graft was also performed. For renal preservation, the right pelvic kidney arteries were perfused with cold Ringer's lactate using a rapid infusion pump and coronary perfusion cannula. The patient's postoperative course was uneventful, and worsening of renal function was not observed. The perfusion of renal arteries with cold Ringer's solution was thought to be a simple and appropriate procedure for renal protection.