Anatomic Suitability For Endovascular Repair Research Articles

Three-Year Safety and Efficacy of the INCRAFT Endograft for Treatment of Abdominal Aortic Aneurysms: Results of the INSIGHT Study.

Preliminary results of the INSIGHT study showed that the low-profile INCRAFT Abdominal Aortic Aneurysm (AAA) Stent-Graft System was safe and effective in the endovascular aneurysm repair (EVAR). This study aimed to assess the durability and the midterm effectiveness of EVAR using the INCRAFT System in the framework of a multicenter, prospective, open-label, post-approval study. Between 2015 and 2016, 150 subjects from 23 European centers treated with the INCRAFT System for an infrarenal AAA were included. Clinical and radiologic data were prospectively collected and analyzed using protocol-specified, monitored follow-up clinic visits at 1, 6, and 12 months post-implantation and annually after that. The clinical success at 3 years was determined. Freedom from overall and aneurysm-related mortality, type I endoleak, secondary interventions, and aneurysm sac enlargement through 3 years were evaluated. Kaplan-Meier estimates were used for late outcomes. An independent clinical events committee reviewed all events. The CT (computed tomography) scans through 1 year were reviewed by an independent core laboratory. The primary clinical success rate at 3 years was 84.0% (126/150). There were no aneurysm-related deaths, endograft migration, or aneurysm-related ruptures through 3 years. Stent fracture was detected in 2 subjects (1.3%) without clinical sequelae. Over 3 years, freedom from overall mortality was 89.4%, freedom from secondary interventions was 80%, and freedom from aneurysm sac enlargement was 96.5%. The 3-year freedom from type IA and IB endoleaks was 93.3% and 98.6%, respectively. In a multicenter real-world study setting, the use of a low-profile INCRAFT device for AAA is associated with sustained clinical success and low rates of reinterventions through 3 years. Low-profile endografts have broadened the spectrum of patients with anatomic suitability for endovascular repair of abdominal aortic aneurysms (AAA). However, questions remain regarding the durability of the repair. The INSIGHT study evaluated the use of the INCRAFT System in routine real-world clinical practice, including patients with complex anatomies. The treatment was safe and effective. The results showed sustained clinical success over 3 years, with no aneurysm-related deaths or ruptures, and a high rate of intervention-free survival at 3 years. Despite the low-profile design of the endograft, the midterm results demonstrate the durability of AAA repair using the INCRAFT System.ClinicalTrials.gov Identifier: NCT02477111.

Intravascular Ultrasound Versus Computed Tomography Angiography in Sizing and Operative Management of Endovascular Aortic Aneurysm Repair

Objectives: An abdominal aortic aneurysm (AAA) is a potentially life-threatening condition, the management of which has dramatically evolved over the past 2 decades with an increasing tendency toward endovascular repair (EVAR) rather than open surgical repair. Classically, contrast-enhanced multislice computed tomography (CT) angiography (CTA) is performed preoperatively for procedure sizing and EVAR planning. This entails voluminous contrast injection with risk of allergic reaction, nephropathy, and radiation exposure. Intra-vascular ultrasound (IVUS) has been increasingly used to guide EVAR procedures intraoperatively. The aim of this study is to investigate the accuracy of IVUS in sizing AAAs, device selection, and EVAR planning compared to the gold standard CTA. Design: This is a prospective observational study enrolling 10 patients who underwent standard infrarenal EVAR procedures performed for unruptured infrarenal AAAs over the course of 1 year. All patients had a preoperative CTA done upon which aneurysm sizing and device planning were performed, and the measurements obtained were compared to those obtained from intraoperative IVUS. Methods: All participating patients had unruptured infrarenal AAA, had no renal impairment, and had anatomical suitability for EVAR according to the instructions for use (IFU) of the device manufacturer. Primary endpoint was comparing anatomical measurements recorded by IVUS with those obtained from the preoperative CTA. Results: Mean age was 65.6 (±6.19), all patients were males and hypertensives and 4 (40%) had a positive family history for AAA. On comparing mean measurements taken by CTA and IVUS, there was no statistically significant differences with exception of maximal aortic diameter and aortic diameter at site of bifurcation (both p-values <.001). There were no statistically significant differences in length measurements between the 2 imaging modalities. Computed tomography angiography was more associated with neck thrombus detection, and IVUS was more associated with calcification detection. Conclusion: Although CT angiography is still the gold standard imaging modality for AAA, IVUS use is very beneficial in EVAR sizing and planning, in addition to intra-operative guidance of the procedure, saving the patient significant time, contrast administration, and radiation exposure, especially in patients with renal impairment and contrast allergy. Clinical Impact A preoperative CT angiogram is the gold standard required investigation for planning and sizing EVARs, with subsequent contrast injection entailing a risk of contrast induced nephropathy and allergic reactions. IVUS has been used as an adjuvant technique to guide EVAR stent graft deployment. However, our study concluded that it can also be reliably used in sizing and planning of the EVAR stent graft along with complementary non contrast imaging, especially in patients with high risk for contrast induced nephropathy and contrast allergy.

Anatomic Suitability for Branched Thoracic Endovascular Repair in Patients with Aortic Arch Pathological Features.

BackgroundEndovascular repair has become a viable alternative for aortic pathological features, including those located within the aortic arch. We investigated the anatomic suitability for branched thoracic endovascular repair in patients previously treated with conventional open surgery for aortic arch pathological features.Methods and ResultsPatients who underwent open surgery for aortic arch pathological features at our institution between 2000 and 2018 were included. Anatomic suitability was determined by strict compliance with the anatomic criteria within manufacturers’ instructions for use for each of the following branched thoracic stent grafts: Relay Plus Double‐Branched (Terumo‐Aortic), TAG Thoracic Branch Endoprosthesis (W.L. Gore & Associates), Zenith Arch Branched Device (Cook‐Medical), and Nexus Stent Graft System (Endospan Ltd/Jotec GmbH). Computed tomography angiography images were analyzed with outer luminal line measurements. A total of 377 patients (mean age, 64±14 years; 64% men) were identified, 153 of whom had suitable computed tomography angiography images for measurements. In total, 59 patients (15.6% of the total cohort and 38.6% of the measured cohort) were eligible for endovascular repair using at least one of the devices. Device suitability was 30.9% for thoracic aneurysms, 4.6% for type A dissections, 62.5% for type B dissections, and 28.6% for other pathological features.ConclusionsThe anatomic suitability for endovascular repair of all aortic arch pathological features was modest. The highest suitability rates were observed for thoracic aneurysms and for type B dissections, of which repair included part of the aortic arch. We suggest endovascular repair of arch pathological features should be reserved for high‐volume centers with experience in endovascular arch repair.

Impact of Renal Chimney Grafts on Anatomical Suitability for Endovascular Repair in Ruptured Abdominal Aortic Aneurysm

Purpose: To evaluate the impact of renal chimney grafts on anatomical suitability for endovascular aneurysm repair (EVAR) in ruptured abdominal aortic aneurysm (rAAA). Methods: Contrast-enhanced computed tomography images of 206 patients with rAAA [175 men (mean age 75±7.8 years) and 31 women (mean age of 76±7.5 years)] were evaluated in a dedicated 3-dimensional vascular workstation. Assessment of infrarenal EVAR suitability was based on predefined anatomical variables reflecting the Instructions for Use of commercially available stent-grafts. In patients where aneurysm neck length was the only limiting factor for suitability, reevaluation of the proximal sealing zone was done, accounting for chimney grafts in one or both renal arteries. Results: Seventy (34%) rAAA patients were anatomically suitable for EVAR: 65 (37%) of 175 men and 5 (16%) of 31 women (p<0.01). Eighty-nine (65%) of the 136 unsuitable patients had aneurysm necks <15 mm long; short neck was the only exclusion criterion in 33 (24%) cases. In the 33 short-necked aneurysms without other limiting factors, a proximal sealing zone >15 mm could potentially be achieved with one or two renal chimney grafts in 12 (36%) and 25 (76%) patients, respectively, increasing overall suitability to 40% and 46%. If access issues could also be solved and a similar strategy with chimneys for the renal arteries was applied, the EVAR suitability would increase further to 58%. Conclusion: Roughly one third of patients with rAAA are anatomically suitable for EVAR; short aneurysm neck is the most common exclusion criteria. In appropriate cases, chimney grafts in one or both renal arteries may increase overall suitability by 12%. Suitability increases to ~60% when iliac access issues are additionally overcome.

Ruptured AAA: Suitability for Endovascular Repair is Associated with Lower Mortality Following Open Repair

Perioperative mortality of open repair of ruptured abdominal aortic aneurysms (rAAA) remains unacceptably high: 30-day mortality ≈ 40 %. This study aimed to assess, quantify, and determine the consequences of anatomic suitability for endovascular repair of rAAA. A retrospective analysis of the prospectively maintained database identified patients with rAAA. Preoperative CT scans were assessed for anatomic suitability for emergency EVAR and precluding factors recorded. Demographic information was collected and analysed for all patients. A total of 141 patients underwent open surgical repair of rAAA. Forty-six patients had preoperative CT scans suitable for reconstruction. Morphological measurements indicated that 41 % would have been anatomically suitable for EVAR. Suitability was associated with lower mortality rates than unsuitability: 0, 11, and 20 % (24 h, 30 days, and 1 year respectively) versus 11, 33, and 59 % (statistically significant at 1 year; p = 0.02). The groups were comparable excepting diabetes incidence, which was higher in those suitable for EVAR (p = 0.003). A minority of patients with ruptured AAA are anatomically suitable for EVAR. Anatomical suitability appears to identify patients at low risk from open surgery. Whether this is due to technically less demanding open surgery is unknown. This may be resolved by the IMPROVE trial results, which are eagerly awaited.

Anatomic suitability for endovascular repair of abdominal aortic aneurysms and possible benefits of low profile delivery systems

The aim of the study was to evaluate the anatomic suitability for endovascular abdominal aneurysm repair (EVAR) according to instructions for use (IFUs) of three commercially available bifurcated stent graft devices and explore the possible benefits of low-profile delivery systems. Computed tomography scans of 241 patients with abdominal aortic aneurysm (AAA) were evaluated for suitability of Zenith Flex(®), Gore Excluder(®) and Endurant(®) bifurcated stent graft systems according to their IFUs. The most common exclusion criteria and possible benefits of smaller diameter delivery systems were analyzed. When choosing the most suitable graft model for each patient, the overall suitability was 49.4%. By brand, the suitability was 28.6% for Zenith(®), 25.7% for Gore Excluder(®) and 48.1% for Endurant(®). By step wise accepting iliac diameters of ≥6 mm, ≥5 mm and ≥4 mm the overall suitability increased to 56.7, 58.9 and 60.2%, respectively (P < 0.001). Diameters below 4 mm had no additional effect on suitability as combinations of other anatomical features, with or without narrow iliacs, accounted for the remaining excluding factors. In conclusion, Less than half of patients with AAAs are suitable for EVAR according to current IFUs. Low-profile delivery systems may allow for endovascular treatment in up to 60% of patients.

Technical Advances With Newer Aortic Endografts Provide Additional Support to Withhold the Early Endovascular Repair of Small Abdominal Aortic Aneurysms Until it is Really Needed.

The idea of early endovascular aortic repair (EVAR) of "small" abdominal aortic aneurysms (AAAs) has gained attention over "watchful waiting," mostly due to the concern for losing the anatomic suitability for endovascular repair over time. Generally, small AAAs have longer, smaller, less angulated necks, and less tortuous iliac arteries than larger ones. Though the borderline anatomic characteristics were assumed to be contraindications for older generation endografts, the modifications of modern devices seem promising to overcome those limitations, in order to treat the small AAAs when reaching the 5.5 cm threshold. Moreover, early endovascular intervention has been proven neither cost effective nor beneficial for the patients' quality of life. This article evaluates the technical progress that could overcome the difficulties of those small AAAs that present technically demanding anatomies, thus advocating endovascular intervention when they reach the diameter threshold.

The influence of aneurysm size on anatomic suitability for endovascular repair

It has been proposed that the threshold for repair of abdominal aortic aneurysms (AAAs) suitable for endovascular repair (EVAR) be lowered. A critical step in this pathway is determining whether smaller AAAs are more likely to be anatomically suitable for EVAR; that is, whether suitability is lost as the AAA grows. Patients who underwent ultrasound (US) imaging for asymptomatic AAAs at the University of Rochester Medical Center between January 1, 2003, and January 31, 2007, were identified. All those who had an abdominal/pelvic computed tomography (CT) scan ≤ 3 months of the US imaging were identified. CT scans were reviewed using predefined criteria to assess anatomic suitability for conventional EVAR (ie, without consideration of debranching). Of 3005 aortic US studies performed during this period, 221 had CT scans showing infrarenal aneurysms. Of these, 168 patients (76%) were candidates for EVAR and 52 (24%) were not, most commonly due to a short neck (40; 77% of excluded). Size measured by CT scanning (mean, 53 ± 11 mm) averaged 4 mm larger than by US imaging (mean, 49 ± 10 mm; r(2) = 0.66; P < .0001). Aneurysm size measured by CT scanning (P < .0001) or US imaging (P < .0001) correlated with anatomic suitability for EVAR. Mean sizes for those suitable were 52 ± 9 mm by CT and 48 ± 7 mm by US imaging, whereas mean sizes for those not suitable were 58 ± 10 mm by CT and 53 ± 8 mm by US imaging. Receiver operating characteristic curve analysis demonstrated that an US cutoff of 4.87 mm best predicted anatomic suitability (86.2% if smaller, 64.8% if larger), whereas a CT cutoff of 57.0 mm best predicted suitability (84.7% if smaller, 63.2% if larger). Aneurysm size measured by CT averaged 4 mm larger than by US imaging. Larger aneurysms are less likely to be anatomically suitable for EVAR, but the rate of suitability does not appreciably decrease until the aneurysm measures 49 mm by US imaging or 57 mm by CT scanning. This implies that waiting until the aneurysm reaches currently accepted size criteria for repair does not result in "missing the window" for EVAR; in other words, just as many patients are anatomically suitable for EVAR at currently accepted size cutoffs than if earlier intervention had been done.

A Comparison of Endovascular Repair versus Open Repair of Abdominal Aortic Aneurysms in a Community Setting

: To compare outcomes between endovascular versus surgical repair of abdominal aortic aneurysms (AAA) in a community hospital setting. : A retrospective analysis of all patients undergoing repair of AAA during 2007. Inclusion criteria included stability and anatomic suitability for endovascular repair (EVAR). Data analyzed included comorbidity, length of stay, complications, and cost to the hospital. : Thirty-one endovascular and 12 open cases fit criteria. There were no significant differences in mortality risk, size of aneurysm, or age between the groups (endovascular 71.6 ± 8 years vs. open 66.7 ± 9 years, P = 0.07). The endovascular group included three patients with contained retroperitoneal rupture, one of whom died secondary to visceral embolization and thrombosis (the only mortality). EVAR was performed with local anesthesia in three and spinal in three cases. Twenty-three cases were performed completely percutaneously. There were no deaths in the surgical group, but four patients experienced major complications. There was no difference between groups in terms of "contribution" costs, but EVAR had significantly greater cost/benefit when measuring "fully loaded" costs (endovascular 4436 ± 7418$ vs. open -1418 ± 6756$, P = 0.02). Endovascular was associated with significantly shorter intensive care unit stay (1.3 ± 0.7 days vs. 2.8 ± 2.1 days, P = 0.001) and overall stay (2.5 ± 2.1 days vs. 7.2 ± 1.6 days, P = 0.001). : Endovascular of AAA seems to be at least equivalent to open repair in terms of acute outcomes, with much improved cost/benefit predominantly linked to reduced length of stay.

RR12. Changes in AAA Neck Morphology and Loss of Anatomic Suitability for EVAR during Surveillance: Does the ”Window of Opportunity” Close for Some Small AAAs?

Growth of small abdominal aortic aneurysms (AAAs) is frequently associated with aortic neck and iliac artery (IA) changes during surveillance. The purpose of this study was to determine the effects of aortic neck and IA changes on anatomic suitability for endovascular aortic aneurysm repair (EVAR) during long-term follow-up, particularly of small AAAs with marginal neck morphology (length < 15 mm and diameter >28 mm). We studied 62 patients with small AAAs (diameter, 4 cm to 5.4 cm) under surveillance with long-term follow-up by CT angiography and 3D reconstructions. The mean follow-up duration was 36 months (interquartile range [IQR], 16-53 months). AAA morphology and changes were measured according to SVS reporting standards. Suitability for EVAR was determined by neck anatomy (diameter, length and angulations, thrombosis), IA morphology and all AAA angulations. The median age of the study cohort was 74 years (IQR, 65-77 years). Marginal necks were present in 22 (35%) small AAAs on initial CTA. Of these AAAs with marginal necks, 74% were considered suitable for EVAR. The median AAA diameter increased from 44.5 mm (IQR, 41-48) to 51.1 mm (IQR, 46-55). The aortic neck diameter increased from 23.0 mm to 25.9 mm (P=.001), whereas neck length decreased from 26.5 mm to 19.0 mm (P<.001). No significant changes in aortic and IA morphology/angulation occurred. Overall, the anatomic suitability for endovascular repair significantly changed during the study period (81% vs 69%; McNemar test, P<.001). Of note, 45% of AAAs with marginal neck morphology vs. 3% of those with adequate necks were not suitable for EVAR at the end of follow-up (P<.001). In fact, AAAs with marginal necks had a 17-fold increased risk of losing anatomic suitability for EVAR during surveillance (odds ratio, 16.8; 95% confidence interval, 4.0-69). Significant changes in aortic neck morphology and EVAR suitability occur during long-term surveillance of small AAAs. EVAR suitability is primarily affected in small AAAs with marginal neck morphology. Our data indicate that early elective EVAR for small AAAs with marginal necks is justified when this is the preferred treatment option, as ongoing surveillance in such patients may result in aortic neck changes that preclude future EVAR.

The Rupture Rate of Large Abdominal Aortic Aneurysms: Is This Modified by Anatomical Suitability for Endovascular Repair?

The Rupture Rate of Large Abdominal Aortic Aneurysms: Is This Modified by Anatomical Suitability for Endovascular Repair?

The Rupture Rate of Large Abdominal Aortic Aneurysms: Is This Modified by Anatomic Suitability for Endovascular Repair?

Conclusion: The presence of diabetes, an aneurysm suitable for endovascular aneurysm repair, and statin medications may lower rupture risk of abdominal aortic aneurysm (AAA). Summary: The authors used a literature review to systematically determine rupture rates of AAAs with initial diameters ≥5 cm in patients not considered for open repair. The data were stratified with respect to aneurysm diameter (<6.0 cm and ≥6.0 cm) and gender, and combined using a random-effects meta-analysis. Post-hoc analyses were also performed. The effect of gender, diabetes, initial AAA diameter, sac length, and aneurysm neck were analyzed with proportional hazards models and regression techniques. Data were also stratified by whether patients were suitable for endovascular repair (EVAR). The authors identified two prospective, two retrospective, and one mixed study for inclusion in the meta-analysis. Patients who had AAA repair were excluded. The overall pooled rupture rate was 18.2 (95% confidence interval [CI], 13.7-24.1) per 100 patient-years. When the aneurysm increased to >6.0 cm, there was a twofold increase in rupture rate vs aneurysms <6 cm (hazard ratio [HR], 2.54; 95% CI, 1.69-3.85). Pooled rupture rates were not significantly higher in women than men. In patients suitable for EVAR from the EVAR-2 trial, rupture rate for a ≥6-cm AAA was 17.4 (95% CI, 12.6-23.4) per 100 patient-years. This was lower than the pooled rate for all five studies (rupture rate, 27.0; 95% CI, 21.1-34.7) per 100 patient-years (P = .026). Patients with diabetes appeared to have a lower rupture rate, and a post hoc analysis indicated that patients taking statins at baseline appeared to have about half the rupture risk compared with those not taking statins. The crude HR for rupture for patients taking statins was 0.52 (95% CI, 0.27-0.98; P = .044). Comment: There are a number of interesting findings in this meta-analysis. Rupture rates for men and women were not significantly different, suggesting that in larger aneurysms, the effect of sex differences may be overwhelmed by aneurysm diameter. In addition, short-necked aneurysms appeared to rupture more often than longer-necked aneurysms, suggesting that part of the benefit of EVAR may be due to the physical characteristics of the aneurysm suitable for EVAR. Perhaps most interesting was that post hoc analysis revealed a potentially great effect for statins in reducing the risk of AAA rupture. This last point, in particular, deserves greater investigation.

Interobserver and Intraobserver Variability of Interpretation of CT-angiography in Patients with a Suspected Abdominal Aortic Aneurysm Rupture

Purpose: To assess interobserver and intraobserver agreement on presence of rupture and determining suitability for endovascular repair (EVAR) on CT angiography (CTA) of patients with a suspected ruptured abdominal aortic aneurysm (RAAA). Methods: For the Amsterdam Acute Aneurysm study, a randomised multicenter trial (ISRCTN66212637), we register all patients with suspected RAAA in the Amsterdam region. For the current analysis 51 consecutive patients were included from this prospective database. Pre operative CT scans were assessed twice with a six-week interval by three vascular surgeons and two interventional radiologists. Variables recorded were presence of rupture, diameter and length of the infrarenal aortic neck, diameters of both iliac arteries and final judgement on anatomical suitability for EVAR. Kappa values for dichotomous outcomes were calculated as a measure of agreement above chance. Continuous outcomes were investigated by calculating the intraclass correlation coefficient (ICC) and by Bland-Altman plots. Results: For presence of rupture group kappa was 0.59 (CI: 0.42–0.77). The group kappa of suitability for EVAR was 0.38 (CI: 0.24–0.51). The ICC for diameter and length of the infrarenal aortic neck and diameters of left and right iliac arteries were 0.40 (CI: 0.26–0.56), 0.47 (CI: 0.32–0.62), 0.61 (CI: 0.48–0.74) and 0.35 (CI: 0.21–0.50) respectively. The Bland-Altman plots confirmed the large variation among observers. Intraobserver kappa ranged from 0.57–0.78 for presence of rupture and 0.40–0.80 for suitability for EVAR. Conclusion: Moderate interobserver agreement was found for presence of rupture and fair agreement for suitability for EVAR. Intraobserver agreement ranged from moderate to almost perfect. Based on this data, optimization of the protocol is mandatory to identify uniform measuring techniques of well defined anatomical criteria for endovascular repair of ruptured aneurysms.

The Rupture Rate of Large Abdominal Aortic Aneurysms

There are no precise estimates of the rate of rupture of large abdominal aortic aneurysms (AAA). There is recent suspicion that anatomic suitability for endovascular repair may be associated with a decreased risk of AAA rupture. Systematic literature review of rupture rates of AAA with initial diameter > or =5 cm in patients not considered for open repair, with stratification by size (<6.0 cm and 6.0+ cm), and gender, combined using random-effects meta-analysis. Proportional hazards regression to analyze factors (including gender, diabetes, initial AAA diameter, aneurysm neck, and sac lengths) associated with rupture in patients anatomically suitable for endovascular repair (EVAR 2 trial). Previous studies (2 prospective, 2 retrospective, and 1 mixed) were identified for meta-analysis and patients with elective repair excluded. The pooled rupture rates was 18.2 [95% confidence interval (CI) 13.7-24.1] per 100 person-years. There was a 2.5-fold increase in rupture rates for patients with AAA of 6.0+ cm versus <6.0 cm, rupture rates = 2.54 (95% CI 1.69-3.85). The pooled rupture rates was nonsignificantly higher in women than men, rupture rates = 1.21 (95% CI 0.77-1.90). For EVAR 2 patients with 6+ cm aneurysms the rupture rates was 17.4 [95% CI 12.9-23.4] per 100 person-years significantly lower than the pooled rate from the meta-analysis, rupture rates = 27.0 [95% CI 21.1-34.7] per 100 person-years, P = 0.026. Patients with shorter neck lengths appeared to have a higher rupture rates than those with longer necks, but this was of borderline significance P = 0.10. Rupture rates of large AAAs reported in different studies are highly variable. There is emerging evidence that patients anatomically suitable for endovascular repair have lower rupture rates.

Surveillance of small aortic aneurysms does not alter anatomic suitability for endovascular repair

Surveillance of small aortic aneurysms does not alter anatomic suitability for endovascular repair

Interobserver and Intraobserver Variability of Interpretation of CT-angiography in Patients with a Suspected Abdominal Aortic Aneurysm Rupture

To assess interobserver and intraobserver agreement on presence of rupture and determining suitability for endovascular repair (EVAR) on CT angiography (CTA) of patients with a suspected ruptured abdominal aortic aneurysm (RAAA). For the Amsterdam Acute Aneurysm study, a randomised multicenter trial (ISRCTN66212637), we register all patients with suspected RAAA in the Amsterdam region. For the current analysis 51 consecutive patients were included from this prospective database. Pre operative CT scans were assessed twice with a six-week interval by three vascular surgeons and two interventional radiologists. Variables recorded were presence of rupture, diameter and length of the infrarenal aortic neck, diameters of both iliac arteries and final judgement on anatomical suitability for EVAR. Kappa values for dichotomous outcomes were calculated as a measure of agreement above chance. Continuous outcomes were investigated by calculating the intraclass correlation coefficient (ICC) and by Bland-Altman plots. For presence of rupture group kappa was 0.59 (CI: 0.42-0.77). The group kappa of suitability for EVAR was 0.38 (CI: 0.24-0.51). The ICC for diameter and length of the infrarenal aortic neck and diameters of left and right iliac arteries were 0.40 (CI: 0.26-0.56), 0.47 (CI: 0.32-0.62), 0.61 (CI: 0.48-0.74) and 0.35 (CI: 0.21-0.50) respectively. The Bland-Altman plots confirmed the large variation among observers. Intraobserver kappa ranged from 0.57-0.78 for presence of rupture and 0.40-0.80 for suitability for EVAR. Moderate interobserver agreement was found for presence of rupture and fair agreement for suitability for EVAR. Intraobserver agreement ranged from moderate to almost perfect. Based on this data, optimization of the protocol is mandatory to identify uniform measuring techniques of well defined anatomical criteria for endovascular repair of ruptured aneurysms.

The Amsterdam Acute Aneurysm Trial: Suitability and Application Rate for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

Purpose To evaluate anatomical suitability and application rate for endovascular repair of patients with a ruptured abdominal aortic aneurysm (RAAA). Methods The Amsterdam Acute Aneurysm trial is a multicenter randomised trial comparing open with endovascular treatment in patients with a RAAA (International Standard Randomized Controlled Trial Number (ISRCTN) 66212637). Between April 2004 and January 2006, all consecutive patients with clinical suspicion of a RAAA at presentation were assessed prospectively. Anatomical suitability for endovascular repair was based on use of an aorto-uni-iliac endovascular graft and assessed in patients with a proven aortic rupture on CT angiography (CTA). Results In 128/256 patients, presenting with clinical suspicion of a ruptured aneurysm, RAAA was diagnosed. 105 patients were brought to a trial center and CTA confirmed RAAA in 83 patients. In 38 of 83 patients (45.8%) with positive CTA, the anatomy of the aorta and iliac arteries was considered suitable for endovascular repair. Exclusion from endovascular repair was due to unsuitable infrarenal neck or iliac anatomy (37 and 8 patients respectively). Overall, endovascular treatment was applicable in 38/128 patients (29.7%) with a RAAA in the Amsterdam region and in 38 out of 105 patients (35.5%) admitted to the trial centers. Conclusion In this prospective cohort of all patients with a RAAA in the Amsterdam Acute Aneurysm Trial region, the suitability for endovascular repair in patients with a RAAA confirmed on CTA is 45.8%, but the application rate was lower.

The Amsterdam Acute Aneurysm Trial: Suitability and Application Rate for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

To evaluate anatomical suitability and application rate for endovascular repair of patients with a ruptured abdominal aortic aneurysm (RAAA). The Amsterdam Acute Aneurysm trial is a multicenter randomised trial comparing open with endovascular treatment in patients with a RAAA (International Standard Randomized Controlled Trial Number (ISRCTN) 66212637). Between April 2004 and January 2006, all consecutive patients with clinical suspicion of a RAAA at presentation were assessed prospectively. Anatomical suitability for endovascular repair was based on use of an aorto-uni-iliac endovascular graft and assessed in patients with a proven aortic rupture on CT angiography (CTA). In 128/256 patients, presenting with clinical suspicion of a ruptured aneurysm, RAAA was diagnosed. 105 patients were brought to a trial center and CTA confirmed RAAA in 83 patients. In 38 of 83 patients (45.8%) with positive CTA, the anatomy of the aorta and iliac arteries was considered suitable for endovascular repair. Exclusion from endovascular repair was due to unsuitable infrarenal neck or iliac anatomy (37 and 8 patients respectively). Overall, endovascular treatment was applicable in 38/128 patients (29.7%) with a RAAA in the Amsterdam region and in 38 out of 105 patients (35.5%) admitted to the trial centers. In this prospective cohort of all patients with a RAAA in the Amsterdam Acute Aneurysm Trial region, the suitability for endovascular repair in patients with a RAAA confirmed on CTA is 45.8%, but the application rate was lower.

Surveillance of small aortic aneurysms does not alter anatomic suitability for endovascular repair

Small abdominal aortic aneurysms (AAAs; 4-5.4 cm) are more likely to be suitable for endovascular aneurysm repair (EVAR) than large aortic aneurysms (>5.5 cm). The purpose of this study was to determine whether small AAA growth is associated with the development of morphologic characteristics that decrease eligibility for EVAR. We studied 54 patients who underwent 2 or more computed tomography scans with 3-dimensional reconstruction during surveillance of small AAAs. Morphologic aortic aneurysm features and changes were measured according to Society for Vascular Surgery reporting standards. Suitability for EVAR was determined by neck anatomy (diameter, length, and angulations), iliac artery morphology, and total aortic aneurysm angulation and tortuosity. The median age of the study cohort was 73 years (interquartile range [IQR], 65-77 years). The median follow-up period was 24 months (IQR, 15-36 months). The median small AAA diameter increased from 44.5 mm (IQR, 41-48 mm) to 48.9 mm (IQR, 45.7-52.0 mm). The median aortic neck diameter increased from 23.0 to 24.0 mm (P = .002), whereas median neck length decreased from 26.5 to 20.0 mm (P = .001). Aortic aneurysm median tortuosity index increased from 1.09 to 1.11 (P = .05). No significant changes in iliac artery morphology occurred. Overall, the anatomic suitability for endovascular repair did not significantly change during the study period (74% vs 69%; McNemar test; P = .25). Changes in aortic morphology are frequently associated with small AAA growth at mid-term follow-up, but such changes are minor and do not affect overall anatomic suitability for EVAR. These data reveal that continued surveillance of small AAAs does not threaten the window of opportunity for EVAR.

Anatomical suitability of ruptured abdominal aortic aneurysms for endovascular repair.

To assess the anatomical suitability of ruptured abdominal aortic aneurysms (AAA) for emergency endovascular repair. All cases (46 patients [35 men; mean age 74 years, range 54-85]) in which computed tomographic angiography (CTA) confirmed AAA rupture over a 5-year period at our university hospital were reviewed for anatomical suitability for endovascular repair. Measurements were made by a radiologist experienced in anatomical assessment of CT criteria for elective endovascular aneurysm repair (EVAR). The mean aneurysm neck length was 18 mm (range 0-59); 17 were conical, 13 straight, 4 barrel, and 6 reverse conical. Six cases had no proximal neck. Overall, 37 (80%) patients were unsuitable for EVAR according to our criteria. Nearly half the patients (22, 48%) had > or =2 adverse features. Unsuitable neck morphology (35, 76%) was the primary reason for exclusion, but CIA aneurysm (10, 22%) and EIA tortuosity (7, 15%) were secondary adverse features. With current stent-graft design, the majority of ruptured abdominal aortic aneurysms are anatomically unsuitable for endovascular repair.