Endovascular Aneurysm Repair Cases Research Articles

The effect of the ratio of aneurysm sac diameter to patient age on the long-term efficacy of different surgical methods for infrarenal abdominal aortic aneurysm

Objective: To investigate the effect of the ratio of the maximum diameter of aneurysm sac to age (R) on the long-term efficacy of endovascular aneurysm repair (EVAR) and open surgical repair (OSR) in patients with infrarenal abdominal aortic aneurysm (IAAA). Methods: This is a retrospective cohort study.The clinical data of 317 patients with IAAA who underwent surgical repair in the Department of Vascular Surgery,the Third Affiliated Hospital of Sun Yat-Sen University from January 2016 to October 2022 were retrospectively collected.There were 266 males and 51 females,aged (69.7±8.3) years (range:37 to 87 years).The R value of the patient was calculated and the receiver operating characteristic(ROC) curve was used to establish a model to calculate the optimal cut-off value.The propensity score matching method was used to match the baseline data of patients in the EVAR and OSR group by 3∶1 (the caliper value was 0.05),and the patients were stratified according to the cutoff value of R,and the postoperative efficacy and survival of the patients were analyzed.The primary endpoint was the total mortality rate,and the secondary endpoints included the occurrence of postoperative complications and reintervention.Pearson χ2 or Fisher 's exact test was used for categorical variables,and t test was used for continuous variables to compare differences between groups.The survival curves of the two groups were described by Kaplan-Meier method. Results: After propensity score matching,198 cases were in the EVAR group and 66 cases were in the OSR group.The ROC model showed that the best cut-off value of R value was 0.90,and the two groups were divided into two layers:R<0.90 and R≥0.90.Among them,112 patients with R<0.90 (84 cases of EVAR,28 cases of OSR);there were 152 patients with R≥0.90 (114 cases of EVAR and 38 cases of OSR).The follow-up time was (23.6±1.6) months (range:1 to 70 months).In the R≥0.90 stratification,the total mortality (26.3% vs.5.3%,P<0.05),complication rate (44.7% vs.26.3%,P<0.05), and secondary intervention rate (31.6% vs.13.2%,P<0.05) in the EVAR group were higher than those in the OSR group.In the R<0.90 stratification,there was no significant difference in the total mortality rate (13.1% vs.10.7%,P<0.05),complication rate (28.6% vs.35.7%,P>0.05) and secondary intervention rate (14.3% vs.21.4%, P>0.05) between the two groups. Conclusions: When R≥0.90 in IAAA patients,OSR maybe more beneficial to patients in terms of survival rate,postoperative complication rate and secondary intervention rate than EVAR.When R<0.90,there are no significant differences in survival rate,complication rate and secondary intervention rate between the two surgical methods.

A Case of Endovascular Aneurysm Repair for Non-anastomotic Pseudoaneurysm in Dacron Vascular Graft for Abdominal Aortic Aneurysm Which is Diagnosed with 4-dimentional Computed Tomography

A Case of Endovascular Aneurysm Repair for Non-anastomotic Pseudoaneurysm in Dacron Vascular Graft for Abdominal Aortic Aneurysm Which is Diagnosed with 4-dimentional Computed Tomography

Locoregional Anesthesia Has Lower Risks of Cardiac Complications Than General Anesthesia After Prolonged Endovascular Repair of Abdominal Aortic Aneurysms

ObjectivesWhile general anesthesia is the primary anesthesia in endovascular aneurysm repair (EVAR), some studies suggested locoregional anesthesia could be a feasible alternative for eligible patients. However, most evidence was from retrospective studies and was subjected to an inherent selection bias that general anesthesia is often chosen for more complex and prolonged cases. To mitigate this selection bias, this study aimed to compare 30-day outcomes of prolonged non-emergent intact infrarenal EVAR in patients undergoing locoregional or general anesthesia. In addition, risk factors associated with prolonged operative time in EVAR were identified. Designretrospective large-scale national registry study. SettingAmerican College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted database from 2012-2022 Participants4075 out of 16,438 (24.79%) patients had prolonged EVAR. Among patients with prolonged EVAR, 324 (7.95%) were under locoregional anesthesia. There were 3,751 (92.05%) under general anesthesia, where 955 of them were matched to the locoregional anesthesia cohort. InterventionsPatients undergoing infrarenal EVAR were included. Exclusion criteria included age<18 years, emergency cases, ruptured AAA, and acute intraoperative conversion to open. Only cases with prolonged operative times (>157 minutes) were selected. A 1:3 propensity-score matching was used to address demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, and concomitant procedures between patients under locoregional and general anesthesia. Thirty-day postoperative outcomes were assessed. Moreover, factors associated with prolonged EVAR were identified by multivariable logistic regression. Measurements and Main ResultsExcept for general anesthesia contraindications, patients undergoing locoregional or general anesthesia exhibited largely similar preoperative characteristics. After propensity-score matching, patients under locoregional and general anesthesia had a lower risk of myocardial infarction (0.93% vs 2.83%, p=0.04) but comparable 30-day mortality (3.72% vs 2.72%, p=0.35) and other complications. Specific concomitant procedures, aneurysm anatomy, and comorbidities associated with prolonged EVAR were identified. ConclusionsLocoregional anesthesia can be a safe and effective alternative to general anesthesia, particularly in EVAR cases with anticipated complexity and prolonged operative times, as it offers the potential benefit of reduced cardiac complications. Risk factors associated with prolonged EVAR can aid in preoperative risk stratification and inform the decision-making process regarding anesthesia choice.

Local Anesthesia for Endovascular Repair of Abdominal Aortic Aneurysm Allows for Accurate Graft Deployment with Durable Results

ObjectiveLocal anesthesia (LA) is sparsely used in endovascular aneurysm repair (EVAR) despite short term benefit, likely secondary to concerns over patient movement preventing accurate endograft deployment. The objective of this study is to examine the association between anesthesia type and endoleak, sac regression, reintervention, and mortality. MethodsThe Vascular Quality Initiative database was queried for all EVAR cases from 2014-2022. Patients were included if they underwent percutaneous elective EVAR with anatomical criteria within instructions for use of commercially approved endografts. Multivariable logistic regression with propensity score weighting lysis was used to determine the association between anesthesia type on the risk of any endoleak noted by intra-operative completion angiogram and sac regression. Multivariable survival analysis with propensity score weighting was used to determine the association between anesthesia type and endoleak at 1 year, long-term reintervention and mortality. Results13932 EVARs met inclusion criteria: 1075 (8%) LA and 12857 (92%) general anesthesia (GA). On completion angiogram, LA was associated with fewer rates of any endoleaks overall (16% vs 24%, p<0.001). On multivariable analysis with propensity score weighting, LA was associated with similar adjusted odds of any endoleak on intra-operative completion angiogram (OR 0.56, 95%CI 0.47-0.68) as well as combined type 1a and type 1b endoleaks (OR 0.72, 05%CI 0.47-1.09). Follow-up computed tomography imaging at 1 year was available for 4892 patients, 377 (8%) LA and 4515 (92%) GA. At 1 year, LA was associated similar rate of freedom from any endoleaks compared to GA (0.66 (95%CI 0.63-0.69) vs 0.71 (95%CI 0.70-0.72), p=0.663) and increased rates of sac regression (50% vs 45% p=0.040). On multivariable analysis with propensity score weighting, LA and GA were associated with similar adjusted odds of sac regression (OR 1.22, 05%CI 0.97-1.55). LA and GA had similar rates endoleak at 1 year (HR 0.14, 95%CI 0.63-1.07), however LA was associated with decreased hazards of combined type 1a and 1b endoleaks at 1 year (HR 0.87, 95%CI 0.80-0.96). LA and GA had similar adjusted long-term reintervention rate (HR 0.77, 95%CI 0.44-1.38) and long-term mortality (HR 1.100, 95%CI 079-1.25). ConclusionLA is not associated with increased adjusted rates of any endoleak on completion angiogram or at 1-year follow-up compared to GA. LA is associated with decreased adjusted rates of yype 1a and type1b endoleak at 1 year, but similar rates of sac regression, long term reintervention and mortality. Concerns for accurate graft deployment should not preclude use of LA and LA should be increasingly considered when deciding on anesthetic type for standard elective EVAR.

Two-Stage Endovascular Aneurysm Repair with Preemptive Embolization: A Retrospective Study

ObjectiveType II endoleak is the most common complication of endovascular aneurysm repair. Retrograde perfusion from the aneurysmal sac side branch to the aneurysmal sac, including the inferior mesenteric artery and lumbar arteries, is associated with adverse events after endovascular aneurysm repair, such as aneurysm sac enlargement, reintervention, rupture, and abdominal aortic aneurysm-related death. Preemptive embolization of the aneurysmal sac side branch before endovascular aneurysm repair is an effective and safe procedure for preventing type II endoleak and reducing the size of the aneurysmal sac. Since 2019, we have been conducting preemptive embolization of the inferior mesenteric artery and lumbar arteries. Thus, we intended to work on a two-stage endovascular aneurysm repair in which embolization and endovascular aneurysm repair are performed on separate days, owing to concerns about prolonged operative time and increased contrast media use and radiation exposure from performing endovascular aneurysm repair simultaneously. This study aimed to evaluate the effects of a two-stage endovascular aneurysm repair. MethodsThis retrospective study included 114 cases of endovascular aneurysm repair (95 men and 19 women) for AAA performed at our hospital between January 2019 and December 2022. Inferior mesenteric artery and lumbar artery embolization were performed simultaneously with endovascular aneurysm repair (simultaneous group) in 49 cases, and two-stage embolization was performed (two-stage group) in 30 cases. The primary endpoints included the occurrence of T2EL during follow-up and the embolization rate of the IMA or LAs. ResultsType II endoleak did not occur in the two-stage group(follow-up period;35±6.2 months), whereas it was observed in 8.2% of patients more than 6 months after EVAR in the simultaneous group(follow-up period;28±5.5months). While the total operative time was 340 ± 111.2 min in the simultaneous group, the durations for embolization and endovascular aneurysm repair in the two-stage group were 169 ± 35.5 min and 135.0 ± 26.4 min (total time 304 ± 31.2 min, p=0.21), respectively, indicating a reduction in the total time required for the two techniques. The total amounts of contrast media used in the simultaneous and two-stage groups were 200.0 ± 179.2 mL and 182.0 ± 51.2 mL(p=0.42), respectively, and the corresponding total radiation doses were 2502.4 ± 690.5 mGy and 2114.6 ± 351.2 mGy (p=0.28), respectively, showing a decrease in both in the two-stage group. The lumbar artery embolization rates were 74.3% and 87.9% (p<0.01) in the simultaneous and two-stage groups, respectively, indicating a significant difference. ConclusionsTwo-stage endovascular aneurysm repair with preemptive embolization of the inferior mesenteric artery and lumbar arteries may be an effective strategy for reducing type II endoleak occurrence, overall operative time, contrast use, and overall radiation exposure.

Investigation of Renal Decline and New Onset Dialysis Following Endovascular Aneurysm Repair in the Vascular Quality Initiative.

The purpose of this study is to identify variables significantly associated with renal function decline after elective endovascular infra-renal abdominal aortic aneurysm repair and to identify the rate and risks of subsequent progression to dialysis. Specifically, we investigate the long-term impact of supra-renal fixation, female gender, and physiologically stressful perioperative events on renal function following endovascular aneurysm repair (EVAR). Review of all EVAR cases in the Vascular Quality Initiative between 2003 and 2021 was conducted to investigate variable associations with three primary outcomes: postoperative acute renal insufficiency (ARI); greater than 30% decline in glomerular filtration rate (GFR) in patients beyond 1year of follow up; and new onset dialysis requirement at any point in follow up. Binary logistic regression analysis was performed for the events of acute renal insufficiency and new onset dialysis requirement. Cox proportional hazard regression was performed regarding long term GFR decline. Postoperative ARI occurred in 3.4% (1692/49772) of patients. Significant (P < .05) association with postoperative ARI was noted for: age (OR 1.014/year, 95% CI 1.008-1.021); female gender (OR 1.44, 95% CI 1.27-1.67); hypertension (OR 1.22, 95% CI 1.04-1.44); chronic obstructive pulmonary disease (OR 1.34, 95% CI 1.20-1.50); anemia (OR 4.24, 95% CI 3.71-4.84); reoperation at index admission (OR 7.86, 95% CI 6.47-9.54); baseline renal insufficiency (OR 2.29, 95% CI 2.03-2.56); larger aneurysm diameter; increased blood loss; and higher volumes of intra-operative crystalloid. Risk factors (P < .05) correlating with a decline of 30% in GFR at any time beyond 1year were: female gender (HR 1.43, 95% CI 1.24-1.65); body mass index (BMI) less than 20 (HR 1.34, 95% CI 1.03-1.74); hypertension (HR 1.38, 95% CI 1.15-1.64); diabetes (HR 1.34, 95% CI 1.17-1.53); COPD (HR 1.21, 95% CI 1.07-1.37); anemia (HR 1.92, 95% CI 1.52-2.42); baseline renal insufficiency (HR 1.31, 95% CI 1.15-1.49); absence of discharge ace-inhibitor (HR 1.27, 95% CI 1.13-1.42); long term re-intervention (HR 2.43, 95% CI 1.84-3.21) and larger AAA diameter. Patients who experienced long term GRF decline had a significantly higher long-term morality. New onset dialysis following EVAR occurred in .47% (234/49772) of those meeting inclusion criteria. Higher rate (P < .05) of new onset dialysis was associated with age (OR 1.03/year, 95% CI 1.02-1.05); diabetes (OR 1.376, 95% CI 1.005-1.885); baseline renal insufficiency (OR 6.32, 95% CI4.59-8.72); Reoperation at index admission (OR 2.41, 95% CI 1.03-5.67); postoperative ARI (OR 23.29, 95% CI 16.99-31.91); absence of beta blocker (OR 1.67, 95% CI 1.12-2.49); long term graft encroachment on renal arteries (OR 4.91, 95% CI 1.49-16.14). New onset dialysis following EVAR is a rare event. Perioperative variables influencing renal function following EVAR include blood loss, arterial injury, and reoperation. Supra-renal fixation is not associated with postoperative acute renal insufficiency or new onset dialysis in long term follow up. Renal protective measures are recommended for patients with baseline renal insufficiency undergoing EVAR as acute renal insufficiency following EVAR portends a 20-fold increased risk of new onset dialysis in long term follow up.

Endovascular Aneurysm Repair for a Patient with Horseshoe Kidney and the Importance of Watershed Sign and Volumetry by Preoperative Contrast-Enhanced Computed Tomography.

We report a case of endovascular aneurysm repair (EVAR) in a patient with horseshoe kidney (HSK) in whom preoperative contrast-enhanced (CE) computed tomography (CT) showed watershed sign. This sign enabled prediction of postoperative renal function by accurate renal volumetry. A 75-year-old man with HSK and a 59-mm abdominal aortic aneurysm was referred for treatment. Preoperative CECT showed watershed lines at the margin of the isthmus, which was perfused by the accessory renal arteries. Using this sign, we calculated the accurate volume of the isthmus, which was 24.5% of the total parenchyma. EVAR was safely performed without renal dysfunction.

Temporal Trends in the Distribution of Open Surgical Repair Versus Endovascular Aneurysm Repair for Abdominal Aortic Aneurysms in the United States: A Vascular Quality Initiative Study

It is well accepted that a shift has occurred in the management of abdominal aortic aneurysms (AAAs) from open surgical repair (OSR) to endovascular aneurysm repair (EVAR) globally. As technology advances, the proportion of OSR vs EVAR cases will change further; however, the effect of aortic diameter size and the urgency of repair on EVAR vs OSR decision making has not been described. The objective of our study was to describe the overall temporal trends and evaluate the effect of aortic urgency on the distribution of OSR vs EVAR choice in the United States during the past two decades.

Ten-year single center experience in elective standard endovascular abdominal aortic aneurysm repair.

Endovascular aneurysm repair (EVAR) has become the treatment of choice for abdominal aortic aneurysm (AAA), demonstrating excellent early outcomes. However, EVAR durability has been questioned in the long-term period. The aim of this study was to assess EVAR outcomes in terms of survival and freedom from re-intervention during a long-term period. All consecutive patients being treated, with elective standard EVAR, in a single tertiary center, were included between 2008 and 2018. Outcomes were defined as survival and freedom from re-intervention and were reported using Kaplan-Meyer lifetables. In subgroup analyses, sex, age (threshold at 65 and 80 years), neck diameter>28mm and type of fixation were also analyzed. Type of re-intervention and endoleak type I (ETIa) were also reported. Five hundred and eight patients (94% males, mean age 72±7.3, mean AAA diameter 59±9mm) were included. The median follow-up was 3 years (range 0-10 years). The survival rate was 92.8% (SE 1.5%), 76.5% (SE 3.1%) and 41.6% (SE 6%), at 2, 5 and 10 years of follow-up, respectively. In total, 78 patients died; 8 deaths (8/75, 10%) were aneurysm related. In multivariate regression analysis, age (CI. 1.02-1.14; p=0.006) and ever tobacco use (CI. 1.02-6.12, P=0.045) were associated with the long-term mortality. Freedom from re-intervention was 96% (SE 1.1%), 93% (SE 1.8%), 85.5% (SE 5%) at 2, 5 and 9 years of follow-up. Limb occlusion was a common complication (n/n; 30% of re-intervention), particularly within the first 2 postoperative years. Six patients presented with rupture and were treated with open conversion. EVAR cases with supra-renal fixation graft presented lower rates of ETIa (CI. 76-87.27, P<0.001). Elective standard EVAR is associated with good long-term survival showing low aneurysm-related mortality. Common risk factors such as advanced age and smoking are associated to higher mortality. The procedure presents low re-intervention rates, while limb occlusion is a complication presented within the first 2 postoperative years.

Mini-endovascular aneurysm repair: a minimalist approach for a minimally invasive procedure.

IntroductionAbdominal aortic aneurysms represent the majority of all aneurysms of the aorta. Endovascular aneurysm repair (EVAR) is an alternative procedure to surgical repair. Although general and regional anaesthesia are frequently used during EVAR procedures, local anaesthesia has become one of the anaesthesia options for which there is increasing experience.AimWe reported our EVAR cases in which we routinely used femoral local anaesthesia.Material and methodsBetween August 2016 and June 2020, the EVAR procedure was applied to 22 infrarenal abdominal aortic aneurysm patients under femoral local anaesthesia. Open femoral artery access through a groin incision was used in all patients. Patients were followed up for graft- and wound-related complications.ResultsThe mean age of the patients was 72.59 ±6.6 years (min: 60, max: 84). Mean aneurysm sac diameter was 61.04 ±8.76 mm. Bifurcated stent graft was used in 21 (95.5%) patients. An aorto-uni-iliac stent graft was used for 1 (4.5%) patient due to contralateral total iliac occlusion. Endoleak was observed in 6 patients. In-hospital mortality was observed in 2 patients; both cases were ruptured with haemodynamic instability (9%). Revision in the groin area was performed in 3 (13.6%) patients due to local wound complications.ConclusionsAlthough the EVAR procedure has been described as a safer and more easily applicable alternative to surgical repair, it is disadvantageous in terms of increasing treatment costs. Anaesthesia preference and incision size with a more minimalist approach can reduce the length of hospital stay and minimize the complications that may occur after the procedure, resulting in decreased costs.

Comparison Outcomes of Anesthesia and Hospitalization of Endovascular Treatment versus Open Surgery for Infra Renal Abdominal Aortic Aneurysm at Sina Hospital from 2011 to 2019

Background: Two methods of repair are currently available for an abdominal aortic aneurysm (AAA), open aneurysm surgery, and endovascular aneurysm repair (EVAR). The purpose of this article is to investigate and compare the outcomes of all cases of open surgery versus EVAR conducted from2011 to 2019 at Sina Medical Research and Training Hospital, the first EVAR was conducted at Sina Hospital in 2011.&#x0D; Methods: This research is a retrospective cross-sectional study. The study population consisted of all abdominal aortic aneurysm patients who were treated at Sina Hospital in Tehran from September 2011 to December 2019. All patients who met the inclusion criteria participated in the study. A checklist of required data was prepared and used to extract data from patients' medical case files. Patients' information was completed via telephone contact with patients or their families. Analyses were performed using SPSS software with a 5-percent error rate.&#x0D; Results: The sample consisted of 194 patients who were divided into two groups. 73 patients (37.6%) underwent open surgery and 121 patients (62.4%) underwent EVAR. All patients (100%) who underwent open surgery received general anesthesia, while only 15 patients (12.8%) who underwent EVAR received general anesthesia, and 102 patients (87.2%) who underwent EVAR received spinal anesthesia. Rates of blood loss and blood transfusion, length of stay in the intensive care unit (ICU), the total length of postoperative hospitalization for patients who underwent open surgery were significantly higher than for those who underwent EVAR (P-value &lt;0.001). The mortality probability of patients with a history of CVA and smoking was3.47 and 2.66 times higher than those with a negative history of these cases, respectively. Although average EF was higher in living patients compared to deceased ones, this difference was not statistically significant (P-value= 0.161).&#x0D; Conclusion: Surgery duration, length of stay in ICU, length of hospital stay, and rate of blood transfusion of patients undergoing EVAR was reduced in comparison with those undergoing open surgery.

Increased Aortic Sac Regression and Decreased Infrarenal Aortic Neck Dilation After Fenestrated Endovascular Aneurysm Repair Compared With Standard Endovascular Aneurysm Repair

Aortic neck dilation (AND) can occur in nearly 25% of patients after EVAR, resulting in loss of proximal seal and aortic rupture. Fenestrated endovascular aneurysm repair (FEVAR) affords increased treatment options for patients with shorter infrarenal aortic necks; however, AND has not been well characterized in these patients. This study sought to compare AND in patients undergoing FEVAR vs standard endovascular aneurysm repair (EVAR). Retrospective review was conducted of prospectively collected data of 20 consecutive FEVAR patients (Cook Zenith fenestrated; Cook Medical, Bloomington, Ind) and 20 EVAR patients (Cook Zenith). Demographic and anatomic characteristics, procedural details, and clinical outcome were analyzed. Preoperative, 1-month postoperative, and longest follow-up computed tomography scans were analyzed using a dedicated three-dimensional workstation. Abdominal aortic aneurysm (AAA) neck diameter was measured in 5-mm increments from the lowest renal artery. Standard statistical analysis was performed. Demographic characteristics did not differ significantly between the two cohorts. The FEVAR group had larger mean aortic diameter at the lowest renal artery, shorter infrarenal aortic neck length, increased prevalence of nonparallel neck shape, and longer AAA length (Table). On follow-up imaging, the suprarenal aortic segment dilated significantly more at all suprarenal locations in the FEVAR cohort, whereas the infrarenal aortic neck segment dilated significantly less compared with the EVAR group (Table). The FEVAR group demonstrated significantly greater sac regression vs the EVAR group. Positive aortic remodeling, as evidenced by increased distance from the celiac axis to the most cephalad margin of the AAA, occurred to a more significant degree in the FEVAR cohort. Device migration, endoleak occurrence, and need for reintervention were similar in both groups. Compared with EVAR, patients undergoing FEVAR had greater extent of suprarenal AND, consistent with a more diseased native proximal aorta. However, the infrarenal neck, which is shorter and also more diseased in FEVAR patients, appears more stable in the postoperative period compared with EVAR cases. Moreover, the FEVAR cohort had significantly greater sac shrinkage and improved aortic remodeling. The suprarenal seal zone in FEVAR may confer a previously undescribed increased level of protection against infrarenal neck dilation and lessen endotension, resulting in more rapid and dramatic sac shrinkage and contributing to a more durable aortic repair.TableDemographics, radiographic data, and outcomes of fenestrated endovascular aneurysm repair (FEVAR) vs endovascular aneurysm repair (EVAR)FEVAREVARP valueDemographics No. of patients20201 Longest CT follow-up, months29.3 ± 16.129.8 ± 16.1.922 Age at procedure, years75.4 ± 9.6775.35 ± 7.07.985 Male85100.231 CAD55501 COPD2510.407 DM1025.407 HTN80801 Active smoker2510.407 Preoperative creatinine level, mg/dL1.06 ± 0.191.07 ± 0.22.88Baseline radiographic data Diameter at lowest renal, mm29.2 ± 7.1924.6 ± 2.94.012 Mean device diameter, mm30.1 ± 3.728.1 ± 3.8.098 Mean device oversizing11.614.3.354 Infrarenal neck length, mm6.65 ± 5.0435.32 ± 14.77<.0001 Nonparallel neck shape8550.041 Severe neck thrombus2010.661 Severe neck calcification551 Length of proximal sealing, mm33.37 ± 9.4531.21 ± 9.19.496 AAA maximum diameter, mm60.44 ± 10.2358.95 ± 11.09.662 AAA length, mm97.12 ± 27.5173.96 ± 18.43.003Diameter changes CA42.22 SMA93.5.0098 +20 mm9.92.7.0008 +15 mm9.92.3.001 +10 mm12.46.2.002 +5 mm13.15.9.002 Lowest renal10.45.9.26 −5 mm9.911.1.77 −10 mm6.712.9.13 −15 mm1.714.3.0009 −20 mm2.116.6.03 AAA maximum diameter−15.7−4.9.04Distance changesCA to aneurysm29.93.4.0167CA to TOG11.713.4.85Outcomes Type IA endoleak on follow-up00N/A Type II endoleak on follow-up3545.748 Branch vessel occlusion00N/A Device-related reintervention1051 All-cause mortality10151 Aorta-related mortality00N/AAAA, Abdominal aortic aneurysm; CA, celiac artery; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; CT, computed tomography; DM, diabetes mellitus; HTN, hypertension; N/A, not applicable; SMA, superior mesenteric artery; TOG, top of graft.Categorical variables are presented as percentage. Continuous variables are presented as mean ± standard deviation. Open table in a new tab

Comparison of manual versus robot-assisted contralateral gate cannulation in patients undergoing endovascular aneurysm repair

Robotic endovascular technology may offer advantages over conventional manual catheter techniques. Our aim was to compare the endovascular catheter path-length (PL) for robotic versus manual contralateral gate cannulation during endovascular aneurysm repair (EVAR), using video motion analysis (VMA). This was a multicentre retrospective cohort study with fluoroscopic video recordings of 24 EVAR cases (14 robotic, 10 manual) performed by experienced operators (> 50 procedures), obtained from four leading European centres. Groups were comparable with no statistically significant differences in aneurysm size (p = 0.47) or vessel tortuosity (p = 0.68). Two trained assessors used VMA to calculate the catheter PL during contralateral gate cannulation for robotic versus manual approaches. There was a high degree of inter-observer reliability (Cronbach's α > 0.99) for VMA. Median robotic PL was 35.7cm [interquartile range, IQR (30.8-51.0)] versus 74.1cm [IQR (44.3-170.4)] for manual cannulation, p = 0.019. Robotic cases had a median cannulation time of 5.33 min [IQR (4.58-6.49)] versus 1.24min [IQR (1.13-1.35)] in manual cases (p = 0.0083). Generated efficiency ratios (PL/aorto-iliac centrelines) was 1.6 (1.2-2.1) in robotic cases versus 2.6 (1.7-7.0) in manual, p = 0.031. Robot-assisted contralateral gate cannulation in EVAR leads to decreased navigation path lengths and increased economy of movement compared with manual catheter techniques. The benefit could be maximised by prioritising robotic catheter shaping over habituated reliance on guidewire manipulation. Robotic technology has the potential to reduce the endovascular footprint during manipulations even for experienced operators with the added advantage of zero radiation exposure.

Iliac Branch Devices With Standard vs Fenestrated/Branched Stent-Grafts: Does Aneurysm Complexity Produce Worse Outcomes? Insights From the pELVIS Registry

Purpose: To compare the outcomes of iliac branch devices (IBD) used in combination with standard endovascular aneurysm repair (EVAR) vs with fenestrated/branched EVAR (f/bEVAR) to treat complex aortoiliac aneurysms. Materials and Methods: The pELVIS Registry database containing the outcomes of IBD use at 8 European centers was interrogated to identify all IBD procedures that were combined with either standard EVAR or f/bEVAR. Among 669 patients extracted from the database, 629 (mean age 72.1±8.8 years; 597 men) had received an IBD combined with standard EVAR vs 40 (mean age 71.1±8.0 years; 40 men) who underwent f/bEVAR with an IBD. The mean aortic aneurysm diameters were 46.4±13.3 mm in the f/bEVAR patients vs 45.0±15.5 mm in the standard EVAR cases. The groups were similar in terms of baseline clinical characteristics and aneurysm morphology. The Kaplan-Meier method was used to compare patient survival, IBD occlusion, type III endoleak, and aneurysm-related reinterventions in follow-up. The estimates are presented with the 95% confidence interval (CI). Results: Technical success was 100% in the f/bEVAR+IBD group and 99% in the EVAR+IBD group (p=0.85). The 30-day mortality was 0% vs 0.5%, respectively (p=0.66), while the 30-day reintervention rates were 7.5% vs 4.1% (p=0.31). The mean follow-up was 32.1±21.3 months for f/bEVAR+IBD patients (n=30) and 35.5±26.8 months for EVAR+IBD patients (n=571; p=0.41). The 12-month survival estimates were 93.4% (95% CI 93.2% to 93.6%) in the EVAR+IBD group vs 93.6% (95% CI 93.3% to 93.9%) for the f/bEVAR+IBD group (p=0.93). There were no occlusions or type III endoleaks in the f/bEVAR+IBD group at 12 months, while the estimates for freedom from occlusion and from type III endoleak in the EVAR+IBD group were 97% (95% CI 96.8% to 97.2%) and 98.5% (95% CI 98.4% to 98.6%), respectively. The 12-month estimates for freedom for aneurysm-related reintervention were 93% (95% CI 92.7% to 93.3%) in the EVAR+IBD group vs 86.4% (95% CI 85.9% to 86.9%) in the f/bEVAR+IBD patients (p=0.046). Conclusion: Treatment of complex aortoiliac disease with f/bEVAR+IBD can achieve equally good early and 1-year outcomes compared to treatment with IBDs and standard bifurcated stent-grafts, except for a somewhat higher reintervention rate in f/bEVAR patients.

Definition of Proficiency Level by a Virtual Simulator as a First Step Toward a Curriculum on Fundamental Skills for Endovascular Aneurysm Repair (EVAR)

At present, there is no proficiency-based curriculum for endovascular treatment of aortic aneurysm repair (EVAR) using virtual reality (VR) surgical simulators, whereas such curricula are available for the treatment of iliac and/or superficial femoral artery disease. The purpose of this work was to compute proficiency, defined by a benchmark level determined by the performance of experts, using a commercial VR simulator as a first step of a curriculum on EVAR. Expert endovascular surgeons (with more than 150 EVAR cases as first operators) from 12 major Italian centers completed three cases of EVAR of increasing difficulty level 3 times each, using the Angio Mentor simulator (by Simbionix) and Gore devices. Proficiency level was based on performance of expert surgeons, as assessed by metrics from a VR simulator. The participating surgeons had a median of 20 years of experience and executed a median of 440 EVAR. For the 3 simulated cases, the following proficiency values were respectively obtained: total procedure time: 22 minutes 32 seconds, 23 minutes 05 seconds, and 20 minutes 32 seconds; total amount of contrast injected: 85.16 mL, 89.97 mL, and 98.01 mL total fluoroscopy time: 10 minutes 39 seconds, 12 minutes 22 seconds, and 10 minutes 17 seconds; time to contralateral gate cannulation: 5 minutes 51 seconds, 7 minutes 09 seconds, and 3 minutes 32 seconds. We computed proficiency levels for 3 simulated cases of EVAR using a VR simulator. Our next step is to determine whether surgical residents can reach this level. Translational research will then be required to assess the impact of such training on real patients.

Successful Endovascular Repair for Abdominal Aortic Aneurysm Presenting as Aortoduodenal Syndrome.

Aortoduodenal syndrome is a rare duodenal obstruction caused by an abdominal aortic aneurysm. Current treatment involves open aneurysmal repair according to the theory that this procedure releases the duodenum from mechanical compression. However, the mechanism of duodenal blockage remains unclear and reports of endovascular aneurysm repair (EVAR) for aortoduodenal syndrome are quite rare. We report our successful case of EVAR for aortoduodenal syndrome without aneurysmal shrinkage and discuss the mechanism of duodenal obstruction.

Importance of Distal Sealing during Endovascular Aneurysm Repair Using Aneurysmal Common Iliac Artery as Landing Zone

Although the use of aneurysmal common iliac artery (CIA) as the landing zone during endovascular aortic aneurysm repair EVAR remains an essential procedure, this procedure may increase the risk of late complications such as ongoing CIA dilatation and type Ib endoleak (CIA-related complications). We hypothesized that incomplete sealing of the aneurysmal CIA segment during EVAR could increase the incidence of CIA-related complications. In this study, we evaluated the midterm results of EVAR with aneurysmal CIA used as the landing zone and assessed the importance of distal sealing in this procedure. We retrospectively reviewed all cases of endovascular aneurysm repair using CIA as landing zone between 2007 and 2015 that had at least 3years' follow-up. We defined aneurysmal CIA as maximum diameter ≥18mm. The main outcome was the incidence of CIA-related complications. We compared midterm results between normal CIA and aneurysmal CIA. Next, we analyzed risk factors for CIA-related complications in aneurysmal CIA. Four complications occurred in normal CIA (mean follow-up, 66.5±22.1months); 21 occurred in aneurysmal CIA (mean follow-up, 62.2±20.5months). The 5-year portion of freedom from CIA-related complications was 97.3% in normal CIA and 69.4% in aneurysmal CIA (P<0.001). Multivariable analysis in aneurysmal CIA showed that unsealed CIA segment length was only risk factor for CIA-related complications. Given the receiver operating characteristic curve results, we defined the unsealed CIA segment ≥10mm as incomplete sealing. The hazard ratio for incomplete sealing associated with CIA-related complications was 3.92 (95% confidence interval 1.62-9.46, P=0.02). Use of aneurysmal CIA as landing zone increases the risk of CIA-related complications. However, maximum sealing of the aneurysmal CIA segment could prevent these complications.

Feature importance of the aortic anatomy on endovascular aneurysm repair (EVAR) using Boruta and Bayesian MCMC

A retrospective study of the abdominal aortic aneurysm (AAA) with EVAR treated patients. The third-party collected the data from twelve vascular centres in Indonesia during 2012-2017. Patient demographics and computed tomography data were evaluated with Osirix MD Software. During five years, we had 148 EVAR cases done using Endurant stent graft (Medtronic). In this paper, we perform Bayesian modelling and selection of feature selection by Boruta. Before performing the models, we will determine the selection of dependent variables start with the Age, Class, and Sex. It will get what is important to be dependent and independent. The difference between Bayesian and the classical method is the introduction of prior information in the form of probability distributions. In addition, to determine the parameters using the Bayesian method obtained from the probability statement. Parameter estimation in Bayesian is no longer a point estimate but, on the contrary, is a statistical distribution. In other words, Bayesian states that a parameter is a variable that has a distribution. Bayesian has become a popular method in modern statistical analysis. Bayesian is applied to a broad spectrum in the scientific and research fields. Bayesian data analysis involves learning from data that uses probability models for many observations and some information to be studied. In other words, analysing statistical models are by combining prior knowledge about the model or parameters of the model. In a nutshell, the simulation results obtained modelling with Bayesian-ZIP-MCMC R2 87.52 and Bayesian-Boruta R2 88.28%.

Open aortic surgery volume experience at a regionalized referral center and impact on Accreditation Council for Graduate Medical Education trainees

ObjectiveThe objective of this study was to review our institute's open aortic surgery volume experience and its impact on Accreditation Council for Graduate Medical Education trainees. MethodsA review was conducted of the vascular surgery department's operative database for all cases that underwent aortic aneurysm repair, whether open aortic repair (OAR), endovascular aneurysm repair (EVAR), or fenestrated EVAR (FEVAR). We also reviewed our graduating trainees' case logs.In the setting of our regionalized referral center, all patients who underwent open or endovascular aortic intervention between 2010 and 2014 at our main campus were included. The total number of aortic procedures performed by our graduation trainees was determined. All aortic aneurysm interventions, both open and endovascular (both EVAR and FEVAR), were included. The main outcome measures were the total number of aortic interventions, any change in trends of intervention, and the total number of open aortic cases that our graduation trainees had. ResultsDuring the 5-year period analyzed, a total of 1389 abdominal aortic aneurysm repair procedures were performed by OAR, EVAR, and FEVAR. Of those, 462 were OARs, representing 33.2% of the total; 440 were EVARs, representing 31.6%; and 487 were FEVARs, representing 35.2%. For all OAR procedures, there was a significant increase in the proportion of these cases over time (P = .014). The total number of EVAR and FEVAR cases performed annually during this time did not change, whereas the number of OAR cases has increased. Of the OARs, 59.3% were performed for juxtarenal aneurysms, whereas 22.9% involved type IV thoracoabdominal aortic aneurysms. On average, graduating vascular surgery trainees performed 23.1 OARs before graduation (range, 19-26). ConclusionsIn contrast to the documented national trend of decreased OAR, our institute continues to see increased OAR relative to EVAR and FEVAR. Moreover, we theorized that the preservation of OAR volume in our program and other similar institutions might offer a practical solution to the challenge of addressing vascular surgery training in aortic surgery by OAR, EVAR, and FEVAR. Inclusive discussions at the national and international levels are needed to reach consensus regarding the future of vascular surgery training and key issues, such as additional, mandatory, subspecialized training in OAR and FEVAR for both residents and fellows who wish to receive certification in OAR; creation of centers of excellence for open aortic surgery that would centralize OAR and direct trainees to those centers for their needed training; and possibly development of new training strategies whereby single cases can be shared among trainees with alternating roles as exposure and closure vs repair.

Recent Advances and Mid-to-Long Term Results of Endovascular Aneurysm Repair for Abdominal Aortic Aneurysms.

Endovascular aneurysm repair (EVAR) has become the standard therapy alongside open surgery repair (OSR) for abdominal aortic aneurysm (AAA) and it is rapidly becoming prevalent. There has been substantial technical progress with respect to EVAR since its introduction. Technical contrivance can be used to manage even inappropriate EVAR cases, including those involving a hostile neck, deficient access route, or aneurysm rupture. However, there are some controversies over reinterventions in relation to long-term outcomes. Although a long-term result has not yet been analyzed in Japan a randomized controlled trial (RCT) held in the West reported that OSR is superior to EVAR for avoiding reinterventions and aneurysm-related death. The RCT involved the use of older devices and proceeded in a different way from the present study; therefore, different results may be obtained for Japanese EVAR outcomes. However, this Western RCT result should be considered as an important warning. Type II endoleak also must be managed in order to improve long term outcomes of EVAR. Efforts to improve both technical methodology and long-term outcomes are necessary to ensure EVAR as a minimally invasive therapy for patients with AAA. (This is a translation of Jpn J Vasc Surg 2018; 27: 405–411.)