Aneurysm-related Death Research Articles

Does Management of True Aneurysms of Peripancreatic Arteries Require Repair of Associated Celiac Artery Stenosis?

True aneurysms of the gastroduodenal (GDA) and pancreaticoduodenal (PDA) arteries have been attributed to increased collateral flow due to tandem celiac artery stenosis or occlusion. Although GDA and PDA aneurysm exclusion is recommended because of the high reported risk of rupture, it remains uncertain whether simultaneous celiac artery reconstruction is necessary to preserve end-organ flow. We conducted a retrospective analysis of consecutive patients admitted from 1996 to 2015 with true aneurysms of the GDA or PDA. Twenty patients with true aneurysms of the PDA (n= 16) or GDA (n= 4) were identified. Mean age was 61.5 years (range 35 to 85 years) and 11 (55%) were women. Nine (45%) presented with rupture, 8 (40%) presented with pain, and 3 (15%) were asymptomatic. All 9 patients who presented with rupture had contained retroperitoneal hematomas, and none experienced rebleeding. Fifteen (75%) patients had an associated celiac artery >60% stenosis or occlusion, and 2 (10%) had both celiac and superior mesenteric artery stenoses. Thirteen (65%) patients underwent successful endovascular coiling, only 1 of which had a prophylactic celiac artery bypass. Three (15%) patients underwent open aneurysm exclusion and celiac bypass, and 4 (20%) others were observed. There were no aneurysm-related deaths in this series, and none of the patients who underwent coiling without celiac revascularization had hepatic ischemia or other mesenteric morbidity develop during a median follow-up of 6 months (maximum 200 months). Gastroduodenal artery and PDA aneurysms present most commonly with pain or bleeding, and all should be considered for repair, regardless of size. Aneurysm exclusion is safely and effectively achieved with endovascular coiling. Although associated celiac artery stenosis is found in the majority of cases, celiac revascularization might not be necessary.

Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial

Short-term survival benefits of endovascular aneurysm repair (EVAR) versus open repair of intact abdominal aortic aneurysms have been shown in randomised trials, but this early survival benefit is lost after a few years. We investigated whether EVAR had a long-term survival benefit compared with open repair. We used data from the EVAR randomised controlled trial (EVAR trial 1), which enrolled 1252 patients from 37 centres in the UK between Sept 1, 1999, and Aug 31, 2004. Patients had to be aged 60 years or older, have aneurysms of at least 5·5 cm in diameter, and deemed suitable and fit for either EVAR or open repair. Eligible patients were randomly assigned (1:1) using computer-generated sequences of randomly permuted blocks stratified by centre to receive either EVAR (n=626) or open repair (n=626). Patients and treating clinicians were aware of group assignments, no masking was used. The primary analysis compared total and aneurysm-related deaths in groups until mid-2015 in the intention-to-treat population. This trial is registered at ISRCTN (ISRCTN55703451). We recruited 1252 patients between Sept 1, 1999, and Aug 31, 2004. 25 patients (four for mortality outcome) were lost to follow-up by June 30, 2015. Over a mean of 12·7 years (SD 1·5; maximum 15·8 years) of follow-up, we recorded 9·3 deaths per 100 person-years in the EVAR group and 8·9 deaths per 100 person-years in the open-repair group (adjusted hazard ratio [HR] 1·11, 95% CI 0·97-1·27, p=0·14). At 0-6 months after randomisation, patients in the EVAR group had a lower mortality (adjusted HR 0·61, 95% CI 0·37-1·02 for total mortality; and 0·47, 0·23-0·93 for aneurysm-related mortality, p=0·031), but beyond 8 years of follow-up open-repair had a significantly lower mortality (adjusted HR 1·25, 95% CI 1·00-1·56, p=0·048 for total mortality; and 5·82, 1·64-20·65, p=0·0064 for aneurysm-related mortality). The increased aneurysm-related mortality in the EVAR group after 8 years was mainly attributable to secondary aneurysm sac rupture (13 deaths [7%] in EVAR vs two [1%] in open repair), with increased cancer mortality also observed in the EVAR group. EVAR has an early survival benefit but an inferior late survival compared with open repair, which needs to be addressed by lifelong surveillance of EVAR and re-intervention if necessary. UK National Institute for Health Research, Camelia Botnar Arterial Research Foundation.

Ultrasound screening for abdominal aortic aneurysms - a rational measure to prevent sudden rupture

The ruptured abdominal aortic aneurysm (AAA) has still a high hospital mortality rate of about 50 % (intervention and non-corrective treatment combined). With an easy non-invasive and inexpensive measure such as the ultrasound screening rupture threatened aneurysms can be recognized in time and then treated prophylactically, hemorrhagic shock can be avoided. Screening programs in England and Sweden currently describe an AAA prevalence of 1.5 % among screened 65-year-old males. With an absolute risk reduction for aneurysm-related death of 15.1 per 10,000 men invited for screening and a cost of £ 7,370 per quality-adjusted life year (QALY), screening for this target group is highly cost-effective. Comprehensive AAA screening requires defined criteria for the quality of the aortic ultrasound examination and for the surgical treatment of detected large AAA. These interventions should be concentrated in centers obligated to quality registry documentation. Patients with smaller AAA, requiring no repair, should be included in a surveillance program, also with registry of their long-term data.

Midterm Outcomes of the Nellix Endovascular Aneurysm Sealing System

Purpose: To report midterm outcomes of the Nellix Endovascular Aneurysm Sealing (EVAS) System in the treatment of abdominal aortic aneurysm (AAA). Methods: Between September 2013 and July 2014, 64 AAA patients (mean age 76.6±6.8 years; 61 men) were treated with the EVAS system at 2 centers (only procedures performed at least 12 months prior to the analysis were included). Most patients were treated for a stable AAA, while 1 patient was treated for a ruptured aneurysm. Mean aneurysm diameter was 57.3±9.3 mm. The proximal neck measured a mean 21.5±3.3 mm in diameter and 27.0±12.1 mm long; the neck angle was 16.9°±19.3°. Eleven (17.2%) patients were treated outside the instructions for use (IFU). Results: Technical success was achieved in 63 (98.4%) of 64 patients; 1 type Ia endoleak was treated intraoperatively. One (1.6%) aneurysm-related death occurred at 4 months due to a secondary aortoenteric fistula. Overall, endoleaks occurred in 3 (4.7%) patients (2 type Ia, 1 type II). The estimated rates for 18-month overall survival, freedom from aneurysm-related death, and freedom from secondary interventions were 92.7%, 98.4%, and 95.0%, respectively. Patients treated outside the IFU had a significantly higher incidence of device-related complications (p=0.03). Conclusion: The use of the Nellix device in everyday clinical practice is safe and offers promising midterm results. The risk of secondary aortoenteric fistula requires further analysis. Longer follow-up is needed to assess the actual efficacy of the device, although the risk of migration with late endoleak seems low.

Postoperative Outcomes of Hybrid Repair in the Treatment of Aortic Arch Aneurysms

The advent of thoracic endovascular aneurysm repair (TEVAR) has bought about a tremendous revolution in the treatment strategy for aortic arch aneurysms. We reviewed our experience using TEVAR with the hybrid approach in the treatment of aortic arch aneurysms to evaluate its feasibility, safety, and effectiveness. Between October 2008 and July 2014, 61 consecutive patients (51 men; mean age 75.8±7.7years; range, 43-85years) underwent elective treatment for aortic arch aneurysms with the hybrid approach. The 61 patients were separated into 2 groups. Thirty-five patients underwent total debranching TEVAR for zone 0 (debranching TEVAR group), 26 patients underwent long elephant trunk (ET) followed by secondary retrograde TEVAR (ET group). Preoperative, perioperative, and follow-up data were collected retrospectively in the database. The technical success rate was 100%. The paraplegia rates in total debranching TEVAR and long ET TEVAR and were 2.9% and 3.8%, respectively. The stroke rates in total debranching TEVAR and long ET TEVAR were 11.4% and 7.7%, respectively. The overall 30-day mortality and in-hospital mortality rates for all 61 patients were 0% and 3.4% (n=2; both were in the total debranching TEVAR group), respectively. There were no perioperative type 1 or 3 endoleaks that required secondary intervention. The mean hospital stay was 15.8days. The median follow-up was 309±303days. No aneurysm-related deaths occurred during follow-up. The hybrid approach can be safely performed with good technical success and good midterm results. In future, new alternative devices for aortic arch pathologies, such as a branched stent graft that eliminates extra-anatomic bypass, should be developed.

Outcomes of type II endoleaks after endovascular abdominal aortic aneurysm (AAA) repair: a single-center, retrospective study

PurposeThis study aims to determine incidence and outcomes of type II endoleaks (T2E) after endovascular abdominal aortic aneurysm repair (EVAR). MethodsA retrospective review of procedural angiograms, computed tomography angiography, and medical records of 202 patients who underwent EVAR with the Gore Excluder stent graft was performed to determine presence and outcomes of T2E. ResultsMedian follow-up time for 163 patients meeting inclusion criteria [136 males (83%)] was 24.7 months (range=0.5–85.2 months). T2E occurred in 66/163 patients (40.5%). Aneurysm sac size was unchanged in 32/66 patients (48.5%), decreased in 22/66 (33.3%), and increased in 12/66 (18.2%). No aneurysm ruptures, conversion to open repair, or aneurysm-related deaths occurred. ConclusionT2E are a common occurrence after EVAR, often with benign outcome. However, routine surveillance should be performed, particularly in patients with persistent endoleak or sac growth.

Low-profile versus standard-profile multibranched thoracoabdominal aortic stent grafts

This study compared midterm results using low-profile stent grafts (LPSGs; 18F) and standard-profile stent grafts (SPSGs; 22F-24F) for endovascular pararenal and thoracoabdominal aortic aneurysm (TAAA) repair. From July 2005 to March 2015, 134 asymptomatic patients underwent endovascular repair of a pararenal or TAAA using multibranched aortic stent grafts. In March 2011, we started using a LPSG with nitinol stents and thin-walled polyester fabric. Prospectively collected data on operative repair, complications, and outcomes were compared between the two groups. LPSGs were used in 37 patients (8 women [21.6%]; mean± standard deviation age, 72.5± 8years) and SPSGs in 97 patients (25 [26%] women; mean age, 73± 8years). Medical comorbidities, aneurysm size, and aneurysm extent were similar in the LPSG and SPSG groups. Mean follow-up time was longer in the SPSG group (3.1± 2years) than in the LPSG group (1.3± 0.9years; P< .001). Operative time, renal failure, stroke, myocardial infarction, and perioperative death were not significantly different between the two groups (P > .05). Aneurysm-related death, rupture, stent graft migration, type I or III endoleaks, aneurysm enlargement >5mm, branch vessel occlusion, and reintervention rates were similar between the two groups (P > .05). However, the combined outcome of conduit use or access artery injury occurred at a lower rate in the LPSG group than in the SPSG group (16% vs 36%; P= .03). Women experienced significantly higher rates of conduit use and access artery injury than men after repair with SPSGs (64% vs 26%, respectively; P= .001) but similar rates after repair with the LPSG (25% vs 14%, respectively; P= .45). LPSGs had similar safety profile and midterm outcomes compared with the SPSGs for treatment of pararenal and TAAA. The substitution of LPSGs for SPSGs lowered the number of patients who required conduit insertion to avoid access artery injury, especially in women, thereby reducing an otherwise striking gender difference.

Risk factors for early renal dysfunction following endovascular aortic aneurysm repair and its effect on the postoperative outcome.

Renal insufficiency is associated with increased morbidity and death after endovascular aortic aneurysm repair (EVAR). However, the effect of postoperative acute kidney dysfunction on patient outcome has not been fully determined. This study aimed to determine the risk factors of early postoperative renal function decline using chronic kidney disease (CKD) staging and its effect on the clinical outcome. A retrospective analysis was performed on a prospectively maintained EVAR database. Pre- and postoperative CKD stages were determined for all patients according to the estimated glomerular filtration rate values. We identified 135 patients who were treated with elective EVAR. CKD stage decline was observed in 25 (19%) of the patients. Freedom from aneurysm-related death was significantly lower in patients with postoperative CKD progression compared with those with unchanged CKD stage. A shaggy aorta without oral beta-blocker administration and higher preoperative serum creatinine levels (>1.4mg/dL) were found to be independent predictors of an early postoperative CKD stage decline. Patients with postoperative CKD progression have an increased frequency of aneurysm-related death. The presence of a shaggy aorta, absence of oral beta-blocker administration and an increased preoperative creatinine level are independent predictors of early postoperative CKD progression.

Natural history and risk factors for rupture of thoracic aortic arch aneurysms

The management of degenerative aneurysms of the aortic arch requires careful selection of patients, taking into consideration risk of rupture and operative risks, which is more relevant with the emergence of hybrid debranching and branched and fenestrated endovascular options. The natural history of true arch aneurysms has not been previously studied. We aimed to determine the expansion rate of thoracic aortic arch aneurysm and to identify predictors for rupture. Consecutive patients with known true thoracic aortic arch aneurysms monitored with serial computed tomography from 2000 to 2014 were retrospectively reviewed. Thoracoabdominal aneurysms and aneurysms due to aortic dissection and connective tissue diseases were excluded. Variables studied included patient demographics, aneurysm morphology, and ascending aorta diameter. A size expansion curve for each patient was plotted with serial computed tomography scan data, and the slope obtained by linear interpolation was taken as the expansion rate. Multiple logistic regression analysis was performed to identify independent predictors of rupture. Average yearly risks of rupture for overall and expansion rate substrata were calculated from life-table analysis. A total of 45 arch aneurysms were followed up for a mean of 36.6months (3-104). Aneurysm growth was largely linear, with an average rate of 2.5mm/y (0-16). During surveillance, 10 aneurysms ruptured (22%) and 8 patients died. There was one additional arch aneurysm-related death during follow-up, whereas 14 patients (31%) died of other causes. Aneurysms expanding at >5.5mm/y have a 67% likelihood of rupture compared with 8.3% of those expanding at<5.5mm/y. Aneurysm size >6.5cm(P= .0001) and hyperlipidemia (P= .0321) were positively correlated with fast expansion. On univariate analysis, only aneurysm size and expansion rate were significant predictors of rupture. On multivariate analysis, aneurysm expansion rate was the sole independent risk factor of aneurysm rupture (odds ratio, 1.43; 95% confidence interval, 1.06-1.92; P= .018). Aneurysm expansion rate >5.5mm/y is a significant rupture predictor in addition to size compared with aneurysm morphology and other demographic factors. Aneurysm size >6.5mm and hyperlipidemia are determining factors of expansion rate. These may have implications in selection of patients for surgery. Better control of hyperlipidemia may alleviate the risk of rupture.

Standard off-the-shelf versus custom-made multibranched thoracoabdominal aortic stent grafts

The complex aortic branch anatomy in thoracoabdominal aortic aneurysms (TAAAs) and pararenal aorticaneurysms (PRAAs) presents a challenge for endovascular repair. The multibranched endovascular device hasdurable midterm results with use of a custom branch stent graft (CSG) configuration. The midterm results with use ofthe standard branch stent graft (SSG) configuration are unknown, but it has the advantage of off-the-shelf technology. The goal of this study was to compare the midterm outcomes of CSG and SSG multibranched endovascular devices. From July 2005 to September 2014, 133 patients underwent elective endovascular repair of TAAA and PRAA in a prospective trial. Beginning in December 2008, SSGs were used in those with suitable anatomy. Fifty patients (mean age, 71± 7years; 11 women [22%]) were treated using SSGs, and 83 patients (mean age, 74± 9years; 22 women [26.5%]) underwent repair using CSGs. The SSG and CSG groups were similar with regard to aneurysm size, aneurysm extent, and medical comorbidities, with the sole exception of lung disease, which was more common in the SSG group. All stent grafts were deployed as intended, with no conversions to open repair. Mean± standard deviation follow-up (days) was 694± 525 for the SSG group and 942± 764 for the CSG group (P= .045). There were no significant differences in aneurysm-related death, renal failure requiring dialysis, stroke, endoleak, visceral or renal branch occlusion, lower extremity weakness, or reintervention (P > .05 for each). The volume of contrast material was significantly lower in those with SSGs compared with CSGs (P= .016), but there were no significant differences in operative or fluoroscopy times. Time to treatment (days from consent to surgery) was significantly lower in SSG patients compared with CSG patients (P= .01). For patients with suitable anatomy, the use of SSGs for TAAA and PRAA repair results in significantly shorter wait times to surgery and is as safe, effective, and durable in the midterm compared with CSGs.

Endovascular Treatment of Degenerative Aneurysms Involving Only the Descending Thoracic Aorta

Purpose: To determine the efficacy of thoracic endovascular aortic repair (TEVAR) for degenerative aneurysm involving only the descending thoracic aorta (DTAA). Methods: An English-language literature review was performed through PubMed, Scopus, and Google Scholar to identify any study evaluating the outcomes of TEVAR for DTAA. The main endpoints of this analysis were all-cause 30-day and late postoperative mortality. Secondary outcome measures were procedure success, vascular access complications, paraplegia, stroke, early endoleaks during the index hospitalization, aneurysm-related death, reinterventions, and conversion to open repair. To control for the anticipated heterogeneity among small observational studies, absolute values and means were pooled using random effects models; the results are expressed as pooled proportions, means, or risk ratio (RR) with 95% confidence intervals (CIs). Results: Eleven studies reporting on 673 patients (mean age 72.6 years, mean aneurysm diameter 62.9 cm) with DTAA were selected for the analysis. Technical success was reported in 91.0% of patients, and vascular access complications requiring repair were encountered in 9.7% of cases. Pooled overall 30-day, 1-year, 2-year, and 3-year survival rates were 96.0%, 80.3%, 77.3%, and 74.0%, respectively. Five studies compared the results of TEVAR after elective (n=151) and urgent/emergent procedure (n=77); the latter was a predictor of 30-day mortality (17.1% vs 1.8%, RR 3.83, 95% CI 1.18 to 12.40, p=0.025). Paraplegia occurred in 3.2% of patients and was permanent in 1.4% of patients. The stroke rate was 2.7%. Early type I endoleak was observed in 7.3%, type II endoleak in 2.0%, and type III in 1.2% of patients. The mean follow-up of 9 studies was 22.3 months. At 3 years, freedom from reintervention was 90.3%. Death secondary to aneurysm rupture and/or fistula was reported in 3.2% of patients. Conclusion: Current results indicate that TEVAR for DTAA can be performed with rather high technical success, low postoperative morbidity, and good 3-year survival.

Fenestrated and branched endovascular aneurysm repair outcomes for type II and III thoracoabdominal aortic aneurysms

Thoracoabdominal aortic aneurysm (TAAA) repair remains a challenging clinical pathology. Endovascular technology, in particular the evolution of fenestrated and branched (F/B) endografts used in endovascular aneurysm repair (EVAR) has provided a less invasive method of treating these complex aneurysms. This study evaluated the technical and clinical outcomes of F/B-EVAR for extensive type II and III TAAA. Data from 354 high-risk patients enrolled in a physician-sponsored investigational device exemption trial (2004-2013) undergoing F/B-EVAR for type II and III TAAA were evaluated. Technical success, perioperative clinical outcomes, and midterm outcomes (36months) for branch patency, reintervention, aneurysm-related death, and all-cause mortality were analyzed. Data are presented as mean± standard deviation and were assessed using Kaplan-Meier, univariate, and multivariate analysis. F/B-EVARs incorporating 1305 fenestration/branches were implanted with 96% of target vessels successfully stented. Completion aortography showed 2.8% patients had a type I or III endoleak. Procedure duration (6.0± 1.7 vs 5.5± 1.6hours; P< .01) and hospital stay (13.1± 10.1 vs 10.2± 7.4days; P< .01) were longer for type II TAAA. Perioperative mortality was greater in type II repairs (7.0% vs 3.5%; P< .001). Permanent spinal cord ischemia occurred in 4% and renal failure requiring hemodialysis occurred in 2.8% of patients. Twenty-seven branches (7.6%) required reintervention for stenosis or occlusion; and celiac artery, superior mesenteric artery, and renal artery secondary patency at 36months was 96% (95% confidence interval [CI], 0.93-0.99), 98% (95% CI, 0.97-1.0), and 98% (95% CI, 0.96-1.0), respectively. Eighty endoleak repairs were performed in 67 patients, including 55 branch-related endoleaks, 4 type Ia, 5 type Ib, and 15 type II endoleaks. At 36months, freedom from aneurysm-related death was 91% (95% CI, 0.88-0.95), and freedom from all-cause mortality was 57% (95% CI, 0.50-0.63). The treatment of type II TAAA (P< .01), age (P<.01), and chronic obstructive pulmonary disease (P< .05) negatively affected survival. F/B-EVAR is a robust treatment option for patients at increased risk for conventional repair of extensive TAAAs. Technical success and branch patency are excellent, but some patients will require reintervention for branch-related endoleak. Aneurysm extent portends a higher risk of perioperative and long-term morbidity and mortality. Additional efforts are needed to improve outcomes and understand the utility of this treatment option in the general TAAA population.

Endovascular Repair of Abdominal Aortic Aneurysm May Not Provide Long-Term Survival Benefit

Purpose: To investigate the long term survival benefit for the treatment of abdominal aortic aneurysmal (AAA) disease with Endovascular Aneurysm Repair (EVAR). Our hypothesis is that patients undergoing EVAR have an equivalent survival to an age matched population. Methods: Between 1997 and 2014 all patients treated for an AAA with EVAR by a single surgeon were prospectively followed and at 12 monthly intervals ultrasonography was utilised to assess the size of the aorta after treatment. Data from the Births, Deaths and Marriages was also collected regarding the survival of these patients. As of 2003 all patients with AAA were treated electively with EVAR. Results: There were a total of 145 patients treated with EVAR for AAA during the study period, 143 who survived the 30-day post-operative period. The long-term survival following EVAR at one year was 95% (95% C.I.: 88% to 97%), at 5 years 56% (95% C.I.: 42% to 64%), and at 10 years 28% (95% C.I.: 17% to 42%). Compared to an age-matched population the EVAR group had a lower than expected long term survival (P < 0.0001). Discussion: EVAR for the treatment of abdominal aortic aneurysms can be achieved with acceptable 30 day survival and freedom from aneurysm related death. However selection of patients for EVAR may significantly effect long-term survival if patients are fit for EVAR but not open operation. The question arises as to whether EVAR should be performed in patients with questionable long-term survival, even if they are fit for this procedure.

The Need for Universal Access to More Flexible Endovascular Stent Graft Constructs

Abdominal aortic aneurysm (AAA) is the 13th leading cause of death in the United States, responsible for over 15,000 deaths annually. With improved screening methods and the advent of endovascular surgery, mortality from AAA has significantly decreased over the past twenty years [1]. Today it is estimated that >70% of aneurysms are amenable to endovascular repair [2]. While endovascular aortic aneurysm repair (EVAR) is confined to the treatment of infra-renal AAA with a ≥10 mm neck, complex endovascular stent grafts have been developed to treat AAA with <4 mm infra-renal neck (juxta-renal), involving the renal or visceral vessel orifices (para-renal or para-visceral), or extending to the diaphragm (Type IV thoraco-abdominal aneurysm) or thoracic aorta. It is estimated that 16% of infrarenal aortic aneurysms are juxta-renal, and a smaller percentage involve the more proximal abdominal aorta [3]. Fenestrated and branched endografts have been developed to treat proximal AAAs not amenable to standard EVAR. However, the extent of what can be treated is limited in the United States by the specific instructions for use (IFU) of each device and what has gone through the rigorous process of FDA approval. Instructions for use outline the recommended anatomic constraints for each device to maximize positive outcomes by guiding patient and device selection. Physicians can treat outside of the IFU but bear significant liability. While certain centers in the US conducting investigational research have access to order endografts outside of their IFU, practitioners in other countries are able to customize devices without these constraints. Patients who could otherwise undergo endovascular repair may be subject to high-risk open surgery, off-label use of devices to perform chimney/snorkel procedures, off-label use of existing FDA approved fenestrated devices, or medical management (at increased risk for aneurysm related death) due to these current restrictions.

Paradigm for Detecting Silent Thoracic Aneurysm Disease

Thoracic aortic aneurysms (TAA) pose a serious detection challenge owing to their clinically silent nature. Only a small fraction of TAAs cause symptoms in patients. However, the mortality burden of this disease in the population is significant, given the high lethality of such complications as aortic rupture and dissection. Widespread screening for TAA has not been shown to be cost-effective. Therefore, currently most patients with a TAA are identified incidentally during an imaging study conducted for other reasons. Once a TAA diagnosis is established, prophylactic surgical treatment can safely be performed for aneurysms of the ascending aorta, aortic arch, and descending or thoracoabdominal aorta, thus preventing aneurysm-related death. To facilitate early detection of TAA, recent studies have identified several "associates" of TAA that may be useful in making a timely diagnosis. These "associates" include intracranial aneurysm, aortic arch anomalies, abdominal aortic aneurysm, simple renal cysts, bicuspid aortic valve, temporal arteritis, a positive family history of aneurysm disease, and a positive thumb-palm sign, among others. Although for many of these "associates" the underlying mechanism that would explain the association remains to be elucidated, the clinical correlation is strong enough to suggest screening patients with these findings for TAA. This article introduces the "Guilt by Association" paradigm for detection of silent thoracic aortic disease based on detection of clinical markers associated with this condition.

Outcomes of surgery for patients with Behcet's disease causing aortic pseudoaneurysm: a shift from open surgery to endovascular repair

OBJECTIVES:Behcet’s disease is a form of systematic vasculitis that affects vessels of various sizes. Aortic pseudoaneurysm is one of the most important causes of death among patients with Behcet’s disease due to its high risk of rupture and associated mortality. Our study aimed to investigate the outcomes of Behcet’s disease patients with aortic pseudoaneurysms undergoing open surgery and endovascular aortic repair.METHODS:From January 2003 to September 2014, ten consecutive patients undergoing surgery for aortic pseudoaneurysm met the diagnostic criteria for Behcet’s disease. Endovascular repair was the preferred modality and open surgery was performed as an alternative. Systemic immunosuppressive medication was administered after Behcet’s disease was definitively diagnosed.RESULTS:Eight patients initially underwent endovascular repair and two patients initially underwent open surgery. The overall success rate was 90% and the only failed case involved the use of the chimney technique to reach a suprarenal location. The median follow-up duration was 23 months. There were 7 recurrences in 5 patients. The median interval between operation and recurrence was 13 months. No significant risk factors for recurrence were identified, but a difference in recurrence between treatment and non-treatment with preoperative immunosuppressive medication preoperatively was notable. Four aneurysm-related deaths occurred within the follow-up period. The overall 1-year, 3-year and 5-year survival rates were 80%, 64% and 48%, respectively.CONCLUSIONS:Both open surgery and endovascular repair are safe and effective for treating aortic pseudoaneurysm in Behcet’s disease patients. The results from our retrospective study indicated that immunosuppressive medication was essential to defer the occurrence and development of recurrent aneurysms.

Aortic neck evolution after endovascular repair with TriVascular Ovation stent graft

Aortic neck dilation has been reported after endovascular aneurysm repair (EVAR) with self-expanding devices. With a core laboratory analysis of morphologic changes, this study evaluated midterm results of aortic neck evolution after EVAR by endograft with no chronic outward force. This was a multicenter registry of all patients undergoing EVAR with the Ovation endograft (TriVascular, Santa Rosa, Calif). Inclusion criteria were at least 24 months of follow-up. Standard computed tomography (CT) scans were reviewed centrally using a dedicated software with multiplanar and volume reconstructions. Proximal aortic neck was segmented into zone A (suprarenal aorta/fixation area), zone B (infrarenal aorta, from lowest renal artery to the first polymer-filled ring), and zone C (infrarenal aorta, at level of the first polymer-filled ring/sealing zone). Images were analyzed for neck enlargement (≥2 mm), graft migration (≥3 mm), endoleak, barb detachment, neck bulging, and patency of the celiac trunk and superior mesenteric and renal arteries. Inclusion criteria were met in 161 patients (mean age, 75.2 years; 92% male). During a mean follow-up period of 32 months (range, 24-50), 17 patients died (no abdominal aortic aneurysm-related death). Primary clinical success at 2 years was 95.1% (defined as absence of aneurysm-related death, type I or type III endoleak, graft infection or thrombosis, aneurysm expansion >5 mm, aneurysm rupture, or conversion to open repair). Assisted primary clinical success was 100%. CT scan images at a minimum follow-up of 2 years were available in 89 cases. Patency of visceral arteries at the level of suprarenal fixation (zone A) was 100%. Neither graft migration nor barb detachment or neck bulging was observed. None of the patients had significant neck enlargement. The mean change in the diameter was 0.18 ± 0.22 mm at zone A, -0.32 ± 0.87 mm at zone B, and -0.06 ± 0.97 mm at zone C. Changes at zone B correlated significantly with changes at zone C (correlation coefficient, 0.183; P = .05), whereas no correlation was found with zone A (correlation coefficient, 0.000; P = 1.0). No aortic neck dilation occurred in this series at CT scan after a minimum 24-month follow-up. This may suggest that aortic neck evolution is not associated with EVAR at midterm follow-up when an endograft with no chronic outward radial force is implanted.

Five-Year Results of the Valor II Trial of the Medtronic Valiant Thoracic Stent Graft

Five-Year Results of the Valor II Trial of the Medtronic Valiant Thoracic Stent Graft

Clinical outcomes of thoracic endovascular aneurysm repair using commercially available fenestrated stent graft (Najuta endograft)

Thoracic endovascular aneurysm repair (TEVAR) for the aortic arch aneurysm is challenging because of its curved anatomic configuration and the presence of the supra-aortic branches. The Najuta fenestrated endograft (Kawasumi Laboratories, Inc, Tokyo, Japan) was developed to treat aortic arch diseases, offering maximal proximal landing length while preserving the blood flow to the supra-aortic branches. We evaluated the perioperative and midterm outcomes of this fenestrated endograft. Between July 2007 and July 2013, 32 patients were treated with the Najuta endograft at three vascular centers. The mean age of the patients was 74.5 ± 9.8 years (23 patients were men). Technical success, complication, overall survival rate, freedom from aneurysm-related death, secondary intervention, aneurysm enlargement, device migration, and patency of supra-aortic branches were investigated retrospectively. The median follow-up period was 2.5 years (range, 0.2-6.2 years). Seventy-one supra-aortic vessels (30 brachiocephalic arteries, 31 left common carotid arteries, 10 left subclavian arteries) were planned to be preserved with fenestrations. Technical success rate was 91% (29 of 32; three type I endoleaks were seen), and five perioperative complications (two Stanford A dissections, one cerebral infarction, one celiac artery obstruction, one spinal cord ischemia) were recognized. Perioperative death was not observed. Overall survival rate and rate of freedom from aneurysm-related death at 3 years were 67% and 97%, respectively. The rate of freedom from secondary intervention and the rate of freedom from aneurysm enlargement at 3 years were 84% and 85%, respectively. Device migration was not observed. There were two branch (left carotid artery and left subclavian artery) occlusions at 2 weeks after TEVAR due to the endograft's infolding. No other branch occlusion was seen in this follow-up period. As a result, the patency rate of the supra-aortic branch was 97% at 3 years. The perioperative and 3-year outcomes of TEVAR using the Najuta precurved, fenestrated endograft demonstrated high freedom from aneurysm enlargement and patency rates of the supra-aortic branches.

Ascending Aortic Aneurysm and Its Clinical Significance: A Case Report

Abstract Aorta, the major conductance vessel of the body, can be affected by a variety of pathologic processes leading to aneurysm, dissection, or ischemic syndromes. There has been a drastic increase in the incidence of aortic aneurysm making it the 18th most common cause for death. When ignored, the patients’ condition might worsen leading to death due to rupture and hemorrhage. Here we report a case of ascending aortic aneurysm affecting the aortic root and proximal part of ascending aorta. Conscious awareness of this pathological process augments a great deal to radiologists and sonographers during various imaging techniques and rescues the patient from aneurysm-related deaths.