Endovascular Aneurysm Repair For Abdominal Aortic Aneurysm Research Articles

Clinical and Radiological Outcomes of Accessory Renal Artery Exclusion during Endovascular Repair of Abdominal Aortic Aneurysms.

Accessory renal arteries (ARAs) frequently coexist with abdominal aortic aneurysms (AAA) and can influence treatment. This study aimed to retrospectively analyze the ARA's exclusion effect on patients undergoing standard endovascular aneurysm repair for AAA. The study focused on medium- and long-term outcomes, including type II endoleak, aneurysmal sac changes, mortality, reoperation rates, renal function, and infarction post-operatively. 76 patients treated with EVAR for AAA were included. One hundred and two ARAs were identified: 69 originated from the neck, 30 from the sac, and 3 from the iliac arteries. The ARA treatment was embolization in 15 patients and coverage in 72. Technical success was 100%. One-month post-operative computed tomography angiography (CTA) revealed that 76 ARAs (74.51%) were excluded. Thirty-day complications included renal deterioration in 7 patients (9.21%) and a blood pressure increase in 15 (19.73%). During follow-up, 16 patients (21.05%) died, with three aneurysm-related deaths (3.94%). ARA-related type II endoleak (T2EL) was significantly associated with the ARA's origin in the aneurysmatic sac. Despite reinterventions were not significantly linked to any factor, post-operative renal infarction was correlated with an ARA diameter greater than 3 mm and ARA embolization. ARAs can influence EVAR outcomes, with anatomical and procedural factors associated with T2EL and renal infarction. Further studies are needed to optimize the management of ARAs during EVAR.

Initial two-day blood pressure management after endovascular aneurysm repair improves midterm outcomes by reducing the incidence of early type II endoleak

ObjectiveThe aim of this study was to evaluate midterm outcomes of our novel strategy of postoperative initial 2-day blood pressure management (BPM) after endovascular aneurysm repair (EVAR) for the prevention of subsequent type II endoleak (T2EL) in a single-center series. MethodsBetween 2008 and 2014, 137 patients who underwent EVAR for abdominal aortic aneurysm (AAA) were reviewed. Starting from 2013, the mean blood pressure was maintained between 75 and 90 mmHg for the initial 24 hours after EVAR followed by systolic pressure controlled below 120 mmHg during the next 24 hours in the treatment group (n = 76). The incidence of T2EL detected at 7 days, reintervention, and AAA sac diameter up to 5 years after EVAR were compared with those of the control group comprising of 60 consecutive patients who underwent standard EVAR without BPM prior to 2013. ResultsBetween the treatment group and the control group, significant differences were achieved in the incidence of T2EL at 7 days (19.7% vs 40.0%; P = .009), a mean decrease of AAA sac diameter at 1-year (−5.1 ± 4.9 vs −2.2 ± 6.7 mm; P = .013) and 2-year (−5.4 ± 7.7 vs −1.7 ± 10.8 mm; P = .045). In addition, there was a significant decrease in the incidence of T2EL detected at 7 days with the use of the Gore Excluder with 22.7% in the treatment group vs 80.0% in the control group (P < .001), which resulted in a significant decrease in the aneurysm sac diameter up to 4 years after EVAR. Survival rate without AAA sac enlargement at 5 years after EVAR (83.0% vs 70.0%; P = .021) in the treatment group was significantly higher than that of the control group, whereas no significant differences were observed in the freedom rates of reintervention, T2EL-related reintervention, and all-cause mortality between the groups. ConclusionsPostoperative initial 2-day BPM had a preventive effect on AAA sac enlargement until midterm periods, by reducing the incidence of T2EL at 7 days after EVAR. The usage of Gore Excluder under BPM was especially associated with sustained positive effects until the midterm follow-up.

Delays in Treatment Are Associated With Increased Mortality in Patients Undergoing Endovascular Repair of Abdominal Aortic Aneurysms

This study aims to evaluate the association between delays in treatment and outcomes after endovascular aneurysm repair (EVAR). A retrospective analysis of consecutive patients undergoing EVAR for abdominal aortic aneurysm (AAA) between January 1998 and December 2019 was performed. Patients undergoing early EVAR (within less than 8 weeks after meeting size threshold for repair) were compared with delayed EVAR (8 weeks or more). The primary outcome was freedom from all-cause mortality. Secondary outcomes were sac regression (defined as a reduction in AAA diameter by 5 mm or more), freedom from reinterventions, 30-day mortality, and complications. Variables were compared using the χ2 test or the Student t test as appropriate. Kaplan-Meier survival curves and Cox regression proportional hazards models were used. A P value of <.05 was considered significant. The study consisted of 513 patients (83% male) with 33% (n = 170) and 67% (n = 343) undergoing early and delayed EVAR, respectively. Early EVAR patients had a larger mean AAA diameter (60 ± 13 mm vs 54 ± 7 mm in delayed EVAR; P < .001). There were no major differences in medical comorbidities between the groups (Table). Operative timing was longer in the early group (119 ± 42 minutes vs 108 ± 45 minutes in delayed; P = .019). Kaplan-Meier survival estimates show that freedom from all-cause mortality was 90% in early EVAR vs 82% in delayed EVAR (P = .023; Fig) at a mean of 25.8 months. Sac regression was similar between the two groups at 54% and 45% for early and delayed EVAR, respectively (P = .304). In addition, freedom from reinterventions was 78% in early EVAR and 83% in delayed EVAR (P = .364). Perioperative mortality was 0% in both groups. Perioperative complication rates were similar at 11% and 9% in early and delayed EVAR, respectively. The Cox regression proportional hazards model showed that delayed EVAR predicted increased mortality (hazard ratio: 1.886, 95% confidence interval [CI]: 1.083-3.285; P = .025). The effect persisted after adjusting for age, AAA diameter, and comorbidities (hazard ratio: 2.597, 95% CI: 1.350-4.998; P = .004). Patient undergoing EVAR within less than 8 weeks after meeting indications for repair tend to have larger aneurysms. Delaying EVAR beyond 8 weeks was associated with increased all-cause mortality after adjusting for preoperative AAA diameter, age, and comorbidities. These findings suggest the need to adopt a pathway that permits expedited treatment within 8 weeks of meeting indications for repair.TableBaseline characteristics of early and delayed EVAR patientsCharacteristicEarlyDelayedP valueAge, mean (SD), years77 (8)77 (8).873Male sex, % (No.)87 (147)80 (275).090Mean AAA diameter, mean (SD), mm60 (13)54 (7)<.001Comorbidities, % (No.) Cardiac37 (63)37 (127).994 Respiratory21 (36)25 (87).296 Hemodialysis01 (4).157 HTN48 (82)55 (189).143 DM12 (20)15 (50).382 Dyslipidemia47 (79)56 (191).049 PAD11 (18)10 (34).811 Active or previous cancer14 (23)11 (36).316 Active smoking15 (24)20 (66).137Medications, % (No.) β-Blockers31 (52)34 (116).437 ACEI/ARB24 (41)34 (116).022 CCB18 (30)21 (73).326 Statin41 (70)53 (182).010 Antiplatelets38 (65)51 (175).006 Anticoagulation11 (19)11 (36).815AAA, Abdominal aortic aneurysm; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blockers; DM, diabetes mellitus; EVAR, endovascular aortic repair; HTN, hypertension; PAD, peripheral arterial disease. Open table in a new tab

Clinical Significance of Lumbar Artery Embolization in Addition to Inferior Mesenteric Artery Embolization to Reduce Persistent Type 2 Endoleak at Endovascular Aneurysm Repair

Persistent type 2 endoleak (T2EL) after endovascular aneurysm repair (EVAR) leads to a higher likelihood of reintervention, sac enlargement, and other adverse outcomes. Although embolization of the inferior mesenteric artery (IMA-E) can decrease T2EL, additional effects of lumbar artery embolization (LA-E) remain undetermined. The aim was to evaluate the effects of pre-emptive LA-E at EVAR on the incidences of persistent T2EL and related complications. Safety and radiation exposure were also analyzed. Consecutive patients who underwent EVAR for abdominal aortic aneurysm between 2013 and 2021 were included. Pre-emptive embolizations were IMA-E before April 2018 and IMA-E plus LA-E thereafter. Patients with occluded IMA/LA, severe renal dysfunction, short life expectancy, or contraindication to contrast agents were not considered for pre-emptive embolization (NO-E). The incidence of T2EL, sac enlargement (>5 mm), reintervention, and other adverse events were compared among three different strategies, as well as radiation time and dose-area products. There were 243, 216, and 158 patients in the NO-E, IMA-E, and LA-E groups, respectively. Statistical differences in the backgrounds were found between age, sex, respiratory impairment, chronic kidney disease, hostile abdomen, aneurysm diameter, proximal neck length, right distal landing length, and device used. T2EL occurred at 20.7%, 24.0%, and 9.7% in the NO-E, IMA-E, and LA-E groups at 1 year, 27.7%, 30.8%, and 12.1% at 2 years, and 29.3%, 30.7%, and 9.8% at 3 years, respectively. After adjustment for confounding factors, LA-E compared with IMA-E was less likely to develop T2EL at 1 year (odds ratio [OR]: 0.31, 95% confidence interval [CI]: 0.14-0.66), 2 years (OR: 0.28, CI: 0.13-0.61), and 3 years (OR: 0.23, CI: 0.08-0.66). Similarly, LA-E compared with NO-E was associated with less T2EL at 1 year (OR: 0.45, CI: 0.21-0.96), 2 years (OR: 0.36, CI: 0.17-0.78), and 3 years (OR: 0.29, CI: 0.10-0.87). Reintervention until 3 years was less frequent after LA-E compared with IMA-E (OR: 0.18, CI: 0.05-0.63) and NO-E (OR: 0.15, CI: 0.04-0.50). Sac shrinkage was larger after LA-E compared with IMA-E (differences, 2.9 ± 1.4 mm) and NO-E (differences, 2.9 ± 1.4 mm). Surgical conversion, sac enlargement, rupture, and aneurysm-related death were not statistically different. No embolization-related complication was reported. Radiation time (minutes) and dose-area products (Gycm2) for NO-E, IMA-E, and LA-E were 61 ± 47, 58 ± 39, and 76 ± 43 (P = .0002) and 432 ± 330, 471 ± 345, and 640 ± 454 (P < .0001), respectively. LA-E in addition to IMA-E can decrease persistent T2EL and reintervention over 3 years. Although excessive radiation exposure limits routine use of LA-E and warrants future innovation on imaging guidance, longer-term effects of LA-E are encouraging.Table IBackground characteristicsNone (n = 243)IMA-E (n = 216)IMA+LA-E (n = 158)P valueAge, mean ± SD77.0 ± 0.674.8 ± 0.675.6 ± 0.7.02Age, median (IQR)78 (72-83)76 (69-81)77 (70-82)Sex, male, No. (%)184 (75.7)187 (86.6)125 (79.1).01HT, No. (%)206 (85.1)181 (83.8)124 (78.5).21DM, No. (%)34 (14.1)33 (15.3)23 (14.6).93Stroke, No. (%)44 (18.2)27 (12.5)30 (19.0).16CAD, No. (%)65 (26.9)50 (23.2)30 (19.0).19Respiratory impairment, No. (%)87 (36.0)76 (35.2)75 (47.5).03Smoking, No. (%)193 (79.4)178 (82.4)118 (74.7).41 Ex/current124/69115/6383/35CKD, No. (%)122 (50.2)85 (39.4)79 (50.0).03 3/4/594/20/873/9/372/5/2Hostile abdomen, No. (%)121 (50.0)95 (44.0)48 (30.4).0005Aneurysm diameter, mean ± SD, mm52.4 ± 9.750.0 ± 7.950.2 ± 7.8.002Proximal neck diameter, mean ± SD, mm22.7 ± 3.522.2 ± 3.722.1 ± 3.3.21Proximal neck length, mean ± SD, mm26.1 ± 12.731.1 ± 15.027.7 ± 12.9.0005Right leg landing CIA/EIA168/67166/4697/58.02 CIA diameter, mean ± SD, mm13.7 ± 2.914.1 ± 2.613.8 ± 2.7.54 EIA diameter, mean ± SD, mm9.1 ± 1.610.0 ± 2.89.8 ± 2.1.08Left leg landing CIA/EIA189/44181/31124/31.38 CIA diameter, mean ± SD, mm13.5 ± 3.513.8 ± 3.114.0 ± 2.8.33 EIA diameter, mean ± SD, mm9.6 ± 2.49.9 ± 2.510.2 ± 2.7.57Device, n (%).008 Endurant133 (54.7)151 (69.9)86 (54.4) Excluder86 (35.4)53 (24.5)56 (35.4) Zenith9 (3.7)4 (1.9)10 (6.3) Others15 (6.2)8 (3.7)6 (3.8)CAD, Coronary artery disease; CIA, common iliac artery; CKD, chronic kidney disease; DM, diabetes mellitus; EIA, external iliac artery; HT, hypertension; IMA-E, embolization of the inferior mesenteric artery; IMA+LA-E, inferior mesenteric artery lumbar artery embolization; IQR, interquartile range; SD, standard deviation.Boldface P values represent significance P < .05. Open table in a new tab Table IIMultivariate analysis adjusted for imbalanced factors in the backgroundsComparisonOR95% CIP valueType 2 endoleak 1 yearIMA vs none1.450.83-2.55.19IMA+LA vs none0.450.21-0.96.04IMA+LA vs IMA0.310.14-0.66.003 2 yearsIMA vs none1.270.74-2.18.39IMA+LA vs none0.360.17-0.78.009IMA+LA vs IMA0.280.13-0.61.001 3 yearsIMA vs none1.300.71-2.38.40IMA+LA vs none0.290.10-0.87.03IMA+LA vs IMA0.230.08-0.66.007Age1.051.01-1.09.009Reintervention Until 3 yearsIMA vs none0.810.44-1.53.52IMA+LA vs none0.150.04-0.50.002IMA+LA vs IMA0.180.05-0.63.008CI, Confidence interval; IMA, inferior mesenteric artery; LA, lumbar artery; OR, odds ratio.Boldface P values represent significance P < .05. Open table in a new tab

Efficacy and safety of prophylactic intraoperative sac embolization in EVAR for abdominal aortic aneurysm: A meta-analysis.

We aimed to investigate the effectiveness and safety of prophylactic sac embolization during endovascular aneurysm repair (EVAR) in patients suffering from abdominal aortic aneurysms. We performed a systematic literature search of PubMed, Web of Science, EMbase, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, Wanfang and China Biomedical Literature Database (CBM) to identify studies evaluating the outcomes of sac embolization vs. no embolization among patients who had received EVAR. The time limit of the search was from the establishing database to July 22, 2022. Outcome measures involved the type II endoleak rate, the other endoleak rate, the reintervention rate, mortality, and operation time. Fixed (no heterogeneity) or random effects models were constructed for each outcome. The outcomes are represented as the odds ratio (OR) with a 95% confidence interval (CI). Among the 2,622 studies screened, 13 studies involving 747 participants were included in the review. The incidence of early-term type II endoleak (OR = 0.2, 95% CI (0.13,0.31), P < 0.00001), mid-term type II endoleak (OR = 0.23, 95% CI (0.15,0.37), P < 0.00001), late-term type II endoleak (OR = 0.27, 95% CI (0.16,0.46), P < 0.00001) and reintervention (OR = 0.50, 95% CI (0.37,0.78), P = 0.002) within the sac embolization group were significantly lower than those in the non-embolization group. No significant differences were observed between the two groups were found for the other endoleak rates (OR = 0.67, 95% CI (0.34,1.32), P = 0.25), mortality (OR = 0.64, 95% CI (0.25,1.66), P = 0.36) and operation time operation (MD = 5.76, 95% CI (-8.30,19.83), P = 0.42). EVAR combined with sac embolization effectively reduces the incidence of type II endoleak and the reintervention rate without enhancing the operation time. Therefore, more high-quality studies are still needed for validation due to the limited amount and quality of included literature. https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022365648.

Intervention followed endovascular aneurysm repair for abdominal aortic aneurysm: a case report

Implementation of a national screening programme for abdominal aortic aneurysm (AAA) in men is on the public health agenda of many western European countries. Its cause 1.3% of all deaths among men aged 65-85 years in developed countries. These aneurysms are typically asymptomatic until the catastrophic event of rupture. The elective open AAA repair carries a 5% mortality. Whereas the 30 days mortality associated with ruptured AAA is widely believed to be around 80%; and of those that reach hospital alive and undergo emergency surgery, approximately 40% will die within 30 days of surgery. An AAA is usually detected on routine examination as a palpable, pulsatile, and non-tender mass. A 65-year-old female did endovascular aneurysm repair for AAA she had hypertension, dyslipidemia, type 2 diabetes on treatment, congestive heart failure with an ejection fraction of 32%. In 3.5 years ago presents with 8 days of fever, severe abdominal pain. Image angiogram showed signs of endovascular aneurysm repair site (intraluminal gas, aneurysm sac). Since she is clinically unfitting for surgery, treated with percutaneous drainage for the aortic collection and antibiotics for long period and periodically follow up.

Vascular Surgery in Japan: 2016 Annual Report by the Japanese Society for Vascular Surgery.

Objectives: This is an annual report indicating the number and early clinical results of annual vascular treatment performed by vascular surgeon in Japan in 2016, as analyzed by database management committee (DBC) members of the JSVS.Materials and Methods: To survey the current status of vascular treatments performed by vascular surgeons in Japan, the DBC members of the JSVS analyzed the vascular treatment data provided by the National Clinical Database (NCD), including the number of treatments and early results such as operative and hospital mortality.Results: In total 136,414 vascular treatments were registered by 1,070 institutions in 2016. This database is composed of 7 fields including treatment of aneurysms, chronic arterial occlusive disease, acute arterial occlusive disease, vascular injury, complication of previous vascular reconstruction, venous diseases, and other vascular treatments. The number of vascular treatments in each field was 21,653, 17,560, 4,983, 2,557, 846, 54,462 and 34,353, respectively. In the field of aneurysm treatment, 19,144 cases of abdominal aortic aneurysm (AAA) including common iliac aneurysm were registered, and 60.3% were treated by endovascular aneurysm repair (EVAR). Among AAA cases, 1,714 (9.4%) cases were registered as ruptured AAA. The operative mortality of ruptured and unruptured AAA was 15.7%, and 0.6%, respectively. 35.9% of ruptured AAA were treated by EVAR, and the EVAR ratio was gradually increasing, but the operative mortality of open repair and EVAR for ruptured AAA was 15.8%, and 15.3%, respectively. Regarding chronic arterial occlusive disease, open repair was performed in 9,303 cases, including 1,329 distal bypasses to the crural or pedal artery, whereas endovascular treatment (EVT) was performed in 8,257 cases. The EVT ratio was gradually increased at 47.0%. The number of varicose vein treatment tremendously increased to 52,639, and 68.5% of the cases were treated by endovenous laser ablations (EVLA). Regarding other vascular operations, 32,779 cases of vascular access operations and 1,411 lower limb amputation surgeries were included.Conclusions: The number of vascular treatments increased since 2011, and the proportion of endovascular procedures increased in almost all field of vascular diseases, especially EVAR for AAA, EVT for chronic arterial occlusive disease, and EVLA for varicose veins. (This is a translation of Jpn J Vasc Surg 2021; 30: 23–41.)

Vascular Surgery in Japan: 2015 Annual Report by the Japanese Society for Vascular Surgery.

Objectives: This is an annual report indicating the number and early clinical results of annual vascular treatment performed by vascular surgeon in Japan in 2015, as analyzed by database management committee (DBC) members of the JSVS.Materials and Methods: To survey the current status of vascular treatments performed by vascular surgeons in Japan, the DBC members of the JSVS analyzed the vascular treatment data provided by the National Clinical Database (NCD), including the number of treatments and early results such as operative and hospital mortality.Results: In total 124,299 vascular treatments were registered by 1,038 institutions in 2015. This database is composed of 7 fields including treatment of aneurysms, chronic arterial occlusive disease, acute arterial occlusive disease, vascular injury, complication of previous vascular reconstruction, venous diseases, and other vascular treatments. The number of vascular treatments in each field was 22,041, 15,671, 4,779, 2,313, 857, 48,837, and 29,801, respectively. In the field of aneurysm treatment, 18,907 cases of abdominal aortic aneurysm (AAA) including common iliac aneurysm were registered, and 57.6% were treated by endovascular aneurysm repair (EVAR). Among AAA cases, 1,850 (9.8%) cases were registered as ruptured AAA. The operative mortality of ruptured and un-ruptured AAA was 16.0%, and 0.6%, respectively. 33.6% of ruptured AAA were treated by EVAR, and the EVAR ratio was gradually increasing, but the operative mortality of open repair and EVAR for ruptured AAA was 16.6%, and 14.5%, respectively. Regarding chronic arterial occlusive disease, open repair was performed in 8,230 cases, including 1,194 distal bypasses to the crural or pedal artery, whereas endovascular treatment (EVT) was performed in 7,441 cases. The EVT ratio was gradually increased at 47.4%. Venous treatment including 47,046 cases with varicose vein treatments and 531 cases with lower limb deep vein thrombosis were registered. Regarding other vascular operations, 29,801 cases of vascular access operations and 1,511 lower limb amputation surgeries were included.Conclusions: The number of vascular treatments increased since 2011, and the proportion of endovascular procedures increased in almost all field of vascular diseases, especially EVAR for AAA, EVT for chronic arterial occlusive disease, and endovenous laser ablation (EVLA) for varicose veins. (This is a translation of Jpn J Vasc Surg 2020; 29: 161–179.)

Association of Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratio with Adverse Events in Endovascular Repair for Abdominal Aortic Aneurysm.

The association of chronic inflammatory markers with the clinical outcome after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) was investigated. We included 230 patients, treated electively with EVAR. The values of neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR) were measured pre- and postoperatively. Any major adverse cardiovascular event (MACE) and acute kidney injury (AKI) were recorded. Adverse events occurred in 12 patients (5.2%). Seven patients suffered from MACE and five from AKI. Median NLR and PLR values were significantly increased after the procedure (NLR: from 3.34 to 8.64, p < 0.001 and PLR: from 11.37 to 17.21, p < 0.001). None of the patients or procedure characteristics were associated with the occurrence of either a MACE or AKI. Receiver operating characteristic curve analysis showed that postoperative NLR and PLR were strongly associated with AKI. A threshold postoperative NLR value of 9.9 was associated with the occurrence of AKI, with a sensitivity of 80% and specificity of 81%. A threshold postoperative PLR value of 22.8 was associated with the occurrence of AKI, with a sensitivity of 80% and specificity of 83%. Postoperative NLR and PLR have been associated with the occurrence of AKI after EVAR for AAA.

High aneurysm wall enhancement values are associated with late sac shrinkage after endovascular repair of abdominal aortic aneurysms.

To analyze the correlation between aneurysm wall enhancement (AWE) values and early and late sac shrinkage after endovascular aneurysm repair (EVAR).We retrospectively analyzed 28 patients who underwent EVAR for abdominal aortic aneurysms (AAA) using a bifurcated main body stent graft. The value of AWE in the slice of the maximum AAA diameter was measured using a volumetric analysis of computed tomography images. Sac measurements before EVAR and more than 10 months after EVAR were compared, and the maximum sac shrinkage rate was calculated.The AWE value immediately after (4 to 7 days) EVAR correlated positively with the sac shrinkage rate (R2 = 0.0139). The AWE value at 6 months after EVAR was also strongly correlated with the sac shrinkage rate (R2 = 0.4982).Higher AWE values at 6 months after EVAR were strongly associated with the sac volume shrinkage rate. High AWE values may be a predictive factor for sac shrinkage and may aid in the selection of the appropriate clinical strategy after EVAR.

Vascular Surgery in Japan: 2014 Annual Report by the Japanese Society for Vascular Surgery.

Objectives: This is an annual report indicating the number and early clinical results of annual vascular treatment performed by vascular surgeon in Japan in 2014, as analyzed by database management committee (DBC) members of the JSVS.Materials and Methods: To survey the current status of vascular treatments performed by vascular surgeons in Japan, the DBC members of the JSVS analyzed the vascular treatment data provided by the National Clinical Database (NCD), including the number of treatments and early results such as operative and hospital mortality.Results: In total 113,296 vascular treatments were registered by 1,002 institutions in 2014. This database is composed of 7 fields including treatment of aneurysms, chronic arterial occlusive disease, acute arterial occlusive disease, vascular injury, complication of previous vascular reconstruction, venous diseases, and other vascular treatments. The number of vascular treatments in each field was 21,085, 14,344, 4,799, 2,088, 1,598, 42,864, and 26,518, respectively. In the field of aneurysm treatment, 17,973 cases of abdominal aortic aneurysm (AAA) including common iliac aneurysm were registered, and 55.7% were treated by endovascular aneurysm repair (EVAR). Among AAA cases, 1,824 (10.1%) cases were registered as ruptured AAA. The operative mortality of ruptured and un-ruptured AAA was 16.1%, and 0.6%, respectively. 32.1% of ruptured AAA were treated by EVAR, and the EVAR ratio was gradually increasing, but the operative mortality of open repair and EVAR for ruptured AAA was 15.7%, and 18.0%, respectively. Regarding chronic arterial occlusive disease, open repair was performed in 8,020 cases, including 1,210 distal bypasses to the crural or pedal artery, whereas endovascular treatment (EVT) were performed in 6,324 cases. The EVT ratio was gradually increased at 44.1%. Venous treatment including 41,246 cases with varicose vein treatments and 520 cases with lower limb deep vein thrombosis were registered. Regarding other vascular operations, 25,024 cases of vascular access operations and 1,322 lower limb amputation surgeries were included.Conclusions: The number of vascular treatments increased since 2011, and the proportion of endovascular procedures increased in almost all field of vascular diseases, especially EVAR for AAA, EVT for chronic arterial occlusive disease, and endovenous laser ablation (EVLA) for varicose veins. (This is a translation of Jpn J Vasc Surg 2020; 29: 15–31.)

Preoperative Neck Angulation is Associated with Aneurysm Sac Growth Due to Persistent Type Ia Endoleak after Endovascular Abdominal Aortic Aneurysm Repair.

Objective: This study aims to determine how instructions for use affect the occurrence of aneurysm sac growth and endoleaks after an endovascular aneurysm repair (EVAR).Materials and Methods: We reviewed 302 patients who underwent EVAR for abdominal aortic aneurysm between 2007 and 2013, and we were able to enroll 159 patients (74% men, mean age 78±7 years) with adequate data (mean follow-up; 48±20 months).Results: The angle of the proximal landing zone (LZ) (hazard ratio: 1.02, 95% confidence interval: 1.00–1.03, p=0.01) was recognized as an independent risk factor of sac growth (≥5 mm). The receiver operating characteristics curve (area under the curve: 0.72) showed a cutoff value of 47° of the minimum angle of the proximal LZ to predict sac growth. Freedom rates for persistent type Ia endoleaks were also found to be lower in the angulated group than those in the other groups (p=0.0095, log-rank).Conclusion: The angle of the proximal LZ was identified as an independent risk factor for sac growth post-EVAR. The incidence of persistent type Ia endoleaks was significantly higher in the angulated group.

Evolving Utility of Endovascular Treatment of Juxtarenal, Pararenal, and Suprarenal Abdominal Aortic Aneurysms Associated With Increased Risk of Mortality Over Time

Continued advances in endovascular technologies are resulting in fewer open abdominal aortic aneurysm (AAA) repairs. In addition, more complex juxtarenal, pararenal, and suprarenal (JPS) AAAs are being managed with various endovascular techniques. This study sought to evaluate the evolving trends in endovascular aneurysm repair (EVAR) of AAAs, hypothesizing increased rate of JPS AAA repair by EVAR. We also sought to evaluate the risk for morbidity and mortality for EVAR and open aneurysm repair (OAR) of JPS AAAs over time. The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for patients undergoing OAR or EVAR for AAAs. A multivariable logistic regression analysis was performed for both infrarenal and JPS AAA repairs. Of 18,661 patients who underwent AAA repair, 3,941 (21.1%) were OAR and 14,720 (78.9%) were EVAR. The rate of OAR decreased from 29.5% in 2011 to 21.3% in 2017 (P<0.001) with a geometric-mean-annual decrease of 27.8%. The rate of EVAR increased from 70.5% to 78.7% during the same time period (P<0.001) with a geometric-mean-annual increase of 11.6%. These trends remained true for both infrarenal and JPS AAAs. After adjusting for covariates, there was no difference in associated risk of 30-day mortality, renal complications, or ischemic colitis for either OAR or EVAR over each incremental year for infrarenal AAAs (P>0.05). However, in patients undergoing EVAR for JPS AAAs, the associated risk of mortality increased with each incremental year (odds ratio [OR]: 1.30, confidence interval [CI]: 1.01-1.69, P=0.039), whereas there was no difference in the risk of mortality for OAR of JPS AAAs with each incremental year (OR: 1.11, CI: 0.99-1.23, P=0.067). The rate of OAR for AAA has decreased over the past seven years with an increase in EVAR, particularly for more complex JPS AAAs. The associated risk for morbidity and mortality for treatment of infrarenal AAAs was not significantly affected by this increased utility of EVAR. The associated risk of mortality for JPS AAAs treated by EVAR increased over time, whereas this trend for associated risk of mortality was not seen for OAR of JPS AAAs. These findings, especially the increased associated risk of mortality over time with EVAR for JPS AAAs, warrant careful prospective analysis.

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

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

Value of Preliminary Selective Lumbar and Inferior Mesenteric Artery Embolization to Prevent Type II Endoleaks After Endovascular Aneurysm Repair

Preliminary selective lumbar artery (LA) and inferior mesenteric artery (IMA) embolization to prevent type II endoleaks (T2ELs) has not been widely evaluated. Our aim was to determine the rate of endoleak and size decrease of infrarenal abdominal aortic aneurysm after endovascular aneurysm repair (EVAR) after pre-emptive coil embolization of IMA and LA in patients at high risk for T2EL. Between September 2014 and September 2019, 139 of 244 patients (56.9%) who underwent EVAR for abdominal aortic aneurysm also underwent selective percutaneous embolization of the IMA and LA before or during EVAR because of risk factors for T2EL. The embolization was performed using either coils or vascular plugs to achieve occlusion of the target vessel confirmed on angiography. Computed tomography and contrast-enhanced ultrasound imaging were performed at 1 month and 6 months and yearly after the procedure to detect endoleaks and to assess the aneurysm sac diameter. Mean follow-up was 23 ± 16 months (range, 1-61 months). Patients had a median of five (range, one to eight) patent LAs and IMAs on preoperative imaging. After completion of embolization, 80% (range, 20%-100%) of direct arterial flow to the aneurysm sack was occluded, with no procedurally related complications. Follow-up imaging showed T2EL in seven patients (5 %). Increase of the aneurysm sac was seen in eight patients during follow-up, of whom two had type I endoleak and six had T2EL. Six T2EL-related interventions were performed during follow-up, of which only one was successful. Shrinkage of the aneurysm sac diameter was in mean 9.2 ± 7.7 mm, which was statistically significant (P < .001). Surgery was required in one patient for proximal type I endoleak. No aneurysm-related death occurred. Preliminary selective LA and IMA embolization for patients at risk for T2EL is safe and effective in preventing development of T2EL. This procedure is associated with rapid decrease in aneurysm sack size.

Efficacy of a novel urinary catheter for men with a local anesthetic injection port for catheter-related bladder discomfort: a randomized controlled study.

The NMOC-3WAY catheter® is a novel urinary catheter for men that can be used to inject a local anesthetic into the urethra. We sought to assess whether the injection of a local anesthetic into the urethra via the NMOC-3WAY catheter® would reduce catheter-related bladder discomfort (CRBD) after endovascular aneurysm repair (EVAR). Adult male patients who underwent elective EVAR for abdominal aortic aneurysms were randomly assigned to the 2% lidocaine group and the normal saline group (control group). CRBD was evaluated at 0, 1, 2, 4, and 6h after surgery. The primary outcome was the incidence of CRBD at 0h after surgery. Data for 37 patients (19 in the lidocaine group and 18 in the control group) were analyzed. CRBD was observed at 0h in six patients (31.6%; mild, n = 5; moderate, n = 1) in the lidocaine group and in five patients (27.8%; mild, n = 1; moderate, n = 3; severe, n = 1) in the control group. The control group showed a tendency to have severe CRBD at 0h, although there was no significant difference in either the incidence (P = 0.80) or severity (P = 0.21) of CRBD between the two groups. Our results suggest that the use of the NMOC-3WAY catheter® for the injection of 2% lidocaine into the urethra does not reduce the incidence of CRBD immediately after EVAR. However, it may reduce moderate or severe CRBD that may lead to postoperative distress and agitation.

Contrast-enhanced ultrasound detects type II endoleaks during follow-up for endovascular aneurysm repair

ObjectiveRepeated computed tomography angiography (CTA) can be used during follow-up visits for endovascular aneurysm repair (EVAR) but leads to accumulated radiation exposure and may cause renal impairment. Therefore, the use of contrast-enhanced ultrasound (CEUS) has increased, and its ability to detect endoleaks has been promising. The aim of this study was to investigate the diagnostic accuracy of CEUS vs CTA for endoleak detection during EVAR follow-up. MethodsNinety-two patients with planned EVAR for abdominal aortic aneurysm were prospectively, consecutively enrolled. In total, 233 paired CTA and CEUS procedures were performed within the same day. Follow-up visits occurred 1 month, 6 months, 12 months, and 24 months postoperatively. ResultsOf 48 endoleaks discovered by CTA, 39 were also detected on CEUS, giving an overall sensitivity of 81.3% and specificity of 98.9%. All undetected endoleaks were minor, without clinical importance, and occurred in patients with high body mass index. ConclusionsIn this study, CEUS was accurate for detecting type II endoleaks during follow-up visits for EVAR. Sensitivity was lower in obese patients. Doppler ultrasound has low sensitivity and seems to be unsuitable for the detection of endoleaks.

Platelets reflect the fate of type II endoleak after endovascular aneurysm repair

ObjectiveThe management of type II endoleak (T2E) remains controversial because of the heterogeneous outcome. For blood-based screening to detect malignant T2E, we focused on platelets after endovascular aneurysm repair (EVAR) and compared them with the prognosis of T2Es. MethodsFrom 2007 to 2015, there were 249 patients treated with EVAR for abdominal aortic aneurysm who were evaluated retrospectively. The mean follow-up period was 3.5 ± 0.2 years. T2Es that had aneurysm sac enlargement or converted to type I or type III endoleak were defined as malignant; the other T2Es were considered benign. Cases without any complications, including T2E, were defined as completed. We compared the platelet count on postoperative days (PODs) 1 to 7 with preoperative baseline values among the three groups. Sequentially, we calculated the cutoff of the platelet ratio on POD 7 to the baseline value in relation to malignant T2E using receiver operating characteristic analysis, and the cutoff ratio was 113% (sensitivity, 79%; specificity, 58%). We then reclassified T2E patients into T2E-high platelet (T2E-HP; ≥113%) or T2E-low platelet (T2E-LP; <113%) groups. The influence of platelets on T2E was evaluated with reintervention rate and cumulative aneurysm sac enlargement rate using the Kaplan-Meier method. ResultsT2Es were found in 70 patients (28%), and 179 patients were assigned to the completed group. Malignant and benign T2Es were found in 33 and 37 patients, respectively. No difference was found in the preoperative baseline values. On POD 7, the platelet count in the malignant T2E group was significantly lower than that in the completed and benign T2E groups (168 × 103/μL vs 207 × 103/μL and 201 × 103/μL; P = .0124). Then, 27 and 43 patients were assigned to the T2E-HP and T2E-LP groups, respectively. The reintervention-free survival rate in the T2E-LP group was lower than that in the completed group (at 3 years, 66.4% ± 8.0% vs 71.9% ± 4.0%; P = .0031). Among T2E patients, the cumulative aneurysm sac enlargement rates in the T2E-LP group were significantly higher than those in the T2E-HP group (at 3 years, 34.6% ± 8.2% vs 20.6% ± 8.2%; P = .0105). Univariate Cox proportional hazards analysis for the cumulative aneurysm sac enlargement rates among T2E patients showed that sex, dual antiplatelet therapy, and lower platelet ratio (<113%) were significant predictors; multivariate analysis showed that T2E-LP was the only significant predictor (hazard ratio, 2.60; P = .0355). ConclusionsThe platelet count of patients with malignant T2Es on POD 7 was definitively lower than that of patients with completed EVAR or with benign T2Es. The lower platelet count on POD 7 could be a risk factor for aneurysm sac enlargement among patients with T2Es.

Vascular Surgery in Japan: 2013 Annual Report by the Japanese Society for Vascular Surgery.

Objectives: This is an annual report indicating the number and early clinical results of annual vascular treatment performed by vascular surgeon in Japan in 2013, as analyzed by database management committee (DBC) members of the JSVS.Materials and Methods: To survey the current status of vascular treatments performed by vascular surgeons in Japan, the DBC members of the JSVS analyzed the vascular treatment data provided by the National Clinical Database (NCD), including the number of treatments and early results such as operative and in-hospital mortality.Results: In total 100,470 vascular treatments were registered by 1,045 institutions in 2013. This database is composed of 7 fields including treatment of aneurysms, chronic arterial occlusive disease, acute arterial occlusive disease, vascular injury, complication of previous vascular reconstruction, venous diseases, and other vascular treatments. The number of vascular treatments in each field was 19,439, 13,276, 4,688, 1,563, 1,777, 37,643, and 23,971, respectively. In the field of aneurysm treatment, 16,694 cases of abdominal aortic aneurysm (AAA) including common iliac aneurysm were registered, and 52.9% were treated by endovascular aneurysm repair (EVAR). Among AAA cases, 1,598 (9.6%) cases were registered as ruptured AAA. The operative mortality of ruptured and un-ruptured AAA was 17.9%, and 1.0%, respectively. 25.5% of ruptured AAA were treated by EVAR, and the EVAR ratio was gradually increasing, but the operative mortality of open repair and EVAR for ruptured AAA was 16.1%, and 15.8%, respectively. Regarding chronic arterial occlusive disease, open repair was performed in 7,437 cases, including 1,121 distal bypasses to the crural or pedal artery, whereas endovascular treatment (EVT) were performed in 5,839 cases. The EVT ratio was gradually increased at 44.0%. Venous treatment including 35,986 cases with varicose vein treatments and 506 cases with lower limb deep vein thrombosis were registered. Regarding other vascular operations, 22,572 cases of vascular access operations and 1,185 amputation surgeries were included.Conclusions: The number of vascular treatments increased since 2011, and the proportion of endovascular procedures increased in almost all field of vascular diseases, especially EVAR for AAA, EVT for chronic arterial occlusive disease, and endovenous laser ablation (EVLA) for varicose veins. (This is a translation of Jpn J Vasc Surg 2019; 28: 273–292.)

Endovascular Aortic Aneurysm Repair without Type 2 Endoleak Using Concomitant N-Butyl-2-Cyanoacrylate Injection into the Abdominal Aortic Aneurysm Sac

The aim of this study was to evaluate our new method to occlude target lumber arteries using N-butyl-2-cyanoacrylate (NBCA) during endovascular aneurysm repair (EVAR) for prevention of type 2 endoleak (T2E). Between 2013 and 2018, 176 patients who underwent EVAR for abdominal aortic aneurysm (AAA) were reviewed. Starting from October 2015, 83 patients (treatment group) underwent NBCA injection into the aneurysmal sac during EVAR. The incidence of T2E at 7days and AAA sac diameter 12months after EVAR were compared with those of the control group comprising 93 consecutive patients who underwent EVAR alone before 2015. The incidence of T2E at 7days was significantly lower in the treatment group (2.4%) than in the control group (22.6%) (P<0.001). AAA sac diameter at 12months in the treatment group had a mean decrease of 6.6mm as compared with the mean 4.4mm in the control group (P=0.026). In multivariate analysis, NBCA injection was significantly related to the reduction of incidence of T2E at 7days (odds ratio=11.8, P<0.001) and a decrease in AAA sac diameter at 12months (P<0.001). There was no NBCA injection-related complication and reintervention in the treatment group. NBCA injection might be safe and useful to reduce the incidence of T2Es and to prevent AAA sac expansion.