Endovascular Aortic Aneurysm Repair Procedures Research Articles

Early experience with patient-specific unibody bifurcated fenestrated-branched devices for complex endovascular aortic aneurysm repair

ObjectiveShort distances between the lowest visceral/renal artery and the aortic bifurcation are technically challenging during complex endovascular aortic aneurysm repair (EVAR), particularly after previous infrarenal repair. Traditionally, inverted limb bifurcated devices have been used in addition to fenestrated-branched (FB) endografts, but short overlap, difficult cannulation, and potential crushing of bridging stents are limitations for their use. This study reviews the early experience of patient-specific company manufactured devices (PS-CMDs) with a unibody bifurcated FB design for complex EVAR. MethodsConsecutive complex EVAR procedures over a 34-month period with unibody bifurcated FB-devices as part of physician-sponsored investigational device exemption studies at two institutions were reviewed. Unibody bifurcated FB designs included FB bifurcated or fenestrated inverted limb devices. End points included technical success, survival, frequency of type I or III endoleaks, limb occlusion, and secondary interventions. ResultsAmong 168 patients undergoing complex EVAR, 33 patients (19.6%; 78.7% male; mean age, 77 years) received unibody bifurcated FB PS-CMDs. FB bifurcated and fenestrated inverted limb devices were used in 31 (93.9%) and 2 (6.06%) patients, respectively. The median maximum aneurysm diameter was 61 mm (interquartile range [IQR], 55-69 mm). Prior EVAR was reported by 29 patients (87.9%), of whom 2 (6.06%) had suprarenal stents. A short distance between the lowest renal artery and aortic bifurcation was demonstrated in 30 patients (90.9%), with median distance of 47 mm (IQR, 38-54 mm). Preloaded devices were used in 23 patients (69.7%). A total of 128 fenestrations were planned; 22 (17.2%) were preloaded with guidewires and 5 (3.9%) with catheters. The median operative time was 238 minutes (226-300 minutes), with a median fluoroscopy time of 65.5 minutes (IQR, 56.0-77.7 minutes) and a median dose area product of 147 mGy∗cm2 (IQR, 105-194 mGy∗cm2). Exclusive femoral access was used in 14 procedures (42.4%). Technical success was 100%. Target vessel primary patency was 100% at a median follow-up time of 11.7 months (IQR, 3.5-18.6 months). Two patients (6.06%) required reintervention for iliac occlusion; one patient required stenting and the other a femoral-femoral bypass. No aortic-related deaths occurred after the procedure. During follow-up, 11 type II endoleaks (33.3%) and 1 type Ib endoleak (3.03%) were detected; the latter was treated with leg extension. No type Ia or III endoleaks occurred. ConclusionsComplex EVAR using unibody bifurcated FB-PS-CMDs is a simple, safe, and cost-effective alternative for the treatment of patients with short distances between the renal arteries and the aortic bifurcation. Further studies are required to assess benefits and durability of unibody bifurcated FB devices.

Cutdown is Associated with Higher 30-day Unplanned Readmissions and Wound Complications than Percutaneous Access for EVAR

ObjectivesA 2023 Cochrane review showed no difference in bleeding/wound infection complications, short-term mortality and aneurysm exclusion between the percutaneous and cut-down approach for femoral access in endovascular aortic aneurysm repair (EVAR). In contrast, single-center studies have shown bilateral cutdown resulting in higher readmission rates due to higher rates of groin wound infections. Whether 30-day readmission rates vary by type of access during EVAR procedures is unknown. The goal of this study was to ascertain which femoral access approach for EVAR is associated with the lowest risk of 30-day readmission. MethodsThe Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing EVAR for aortic disease from 2012-2021. All ruptures and other emergency cases were excluded. Cohorts were divided into bilateral cutdown, unilateral cutdown, failed percutaneous attempt converted to open and successful percutaneous access. The primary 30-day outcomes were unplanned readmission and wound complications. Univariate analyses were performed using the Fisher’s exact test, Chi-Square test and the Student’s t-test. Multivariable analysis was performed using logistic regression. ResultsFrom 2012 to 2021, 14,002 patients met study criteria. Most (7,395 [53%]) underwent completely percutaneous access, 5,616 (40%) underwent bilateral cutdown, 849 (6%) underwent unilateral cutdown, and 146 (1%) had a failed percutaneous access which was converted to open. Unplanned readmissions by access strategy included 7.6% for bilateral cutdown, 7.3% for unilateral cutdown, 7.8% for attempted percutaneous converted to cutdown, and 5.7% for completely percutaneous access (p<.001, Figure 1). After multivariable analysis, unplanned readmissions compared to percutaneous access yielded: percutaneous converted to cutdown adjusted odds ratio (AOR): 1.38, 95% CI [0.76-2.53], p=.29; unilateral cutdown AOR: 1.18, 95% CI [0.92-1.51], p=.20; bilateral cutdown AOR: 1.26, 95% CI [1.09-1.43], p=.001. Bilateral cutdown was also associated with higher wound complications compared to percutaneous access (AOR: 4.41, CI [2.86-6.79], p<.001), as was unilateral cutdown (AOR: 3.04, CI [1.46-6.32], p=.003). ConclusionPatients undergoing cutdown for EVAR are at higher risk for 30-day readmission compared to completely percutaneous access. If patient anatomy allows for percutaneous EVAR, this access option should be prioritized.

Editor's Choice – Outcomes Following Intact and Ruptured Aneurysm Repair across Nations: Analysis of International Registry Data from the VASCUNET Collaboration 2014 – 2019

To determine the peri-operative mortality rate for intact and ruptured abdominal aortic aneurysm (AAA) repair in 10 countries and to compare practice and outcomes over a six year period by age, sex, and geographic location. This VASCUNET study used prospectively collected data from vascular registries in 10 countries on primary repair of intact and ruptured AAAs undertaken between January 2014 and December 2019. The primary outcome was peri-operative death (30 day or in hospital). Logistic regression models were used to estimate the association between peri-operative death, patient characteristics, and type of procedure. Factors associated with the use of endovascular aortic aneurysm repair (EVAR) were also evaluated. The analysis included 50 642 intact and 9 453 ruptured AAA repairs. The proportion of EVARs for intact repairs increased from 63.4% in 2014 to 67.3% in 2016 before falling to 62.3% in 2019 (p < .001), but practice varied between countries. EVAR procedures were more common among older patients (p < .001) and men (p<.001). Overall peri-operative mortality after intact AAA repair was 1.4% (95% confidence interval [CI] 1.3- 1.5%) and did not change over time. Mortality rates were stable within countries. Among ruptured AAA repairs, the proportion of EVARs increased from 23.7% in 2014 to 35.2% in 2019 (p < .001). The average aortic diameter was 7.8 cm for men and 7.0 cm for women (p < .001). The overall peri-operative mortality rate was 31.3% (95% CI 30.4 - 32.2%); the rates were 36.0% (95% CI 34.9 - 37.2%) for open repair and 19.7% (95% CI 18.2 - 21.3%) for EVAR. This difference and shift to EVAR reduced peri-operative mortality from 32.6% (in 2014) to 28.7% (in 2019). The international practice of intact AAA repair was associated with low mortality rates in registry reported data. There remains variation in the use of EVAR for intact AAAs across countries. Overall peri-operative mortality remains high after ruptured AAA, but an increased use of EVAR has reduced rates over time.

Long-term outcomes of staged iliofemoral endoconduits prior to complex endovascular aortic aneurysm repair

ObjectiveAdverse iliofemoral anatomy may preclude complex endovascular aortic aneurysm repair (EVAR). In our practice, staged iliofemoral endoconduits (ECs) are planned prior to complex EVAR to improve vascular access and decrease operative time while allowing the stented vessel to heal. This study describes the long-term results of iliofemoral ECs prior to complex EVAR. MethodsBetween 2012 and 2023, 59 patients (44% male; median age, 75 ± 6 years) underwent ECs before complex EVAR using self-expanding covered stents (Viabahn). For common femoral artery (CFA) disease, ECs were delivered percutaneously from contralateral femoral access and extended into the CFA to preserve the future access site for stent graft delivery. Internal iliac artery patency was maintained when feasible. During complex EVAR, the EC extended into the CFA was directly accessed and sequentially dilated until it could accommodate the endograft. Technical success was defined as successful access, closure, and delivery of the endograft during complex EVAR. Endpoints were vascular injury or EC disruption, secondary interventions, and EC patency. ResultsUnilateral EC was performed in 45 patients (76%). ECs were extended into the CFA in 21 patients (35%). Median diameters of the native common iliac, external iliac, and CFA were 7 mm (interquartile range [IQR], 6-8 mm), 6 mm (IQR, 5-7 mm), and 6 mm (IQR, 6-7 mm), respectively. Internal iliac artery was inadvertently excluded in 10 patients (17%). Six patients (10%) had an intraoperative vascular injury during the EC procedure, and six patients (10%) had EC disruption during complex EVAR, including five EC collapses requiring re-stenting and one EC fracture requiring open cut-down and reconstruction with patch angioplasty. In 23 patients (39%), 22 Fr OD devices were used; 20 Fr were used in 22 patients (37%), and 18 Fr in 14 patients (24%). Technical success for accessing EC was 89%. There was no difference in major adverse events at 30 days between the iliac ECs and iliofemoral ECs. Primary patency by Kaplan-Meier estimates at 1, 3, and 5 years were 97.5%, 89%, and 82%, respectively. There was no difference in primary patency between iliac and iliofemoral ECs. Six secondary interventions (10%) were required. The mean follow-up was 34 ± 27 months; no limb loss or amputations occurred during the follow-up. ConclusionsECs improve vascular access, and their use prior to complex EVAR is associated with low rates of vascular injury, high technical success, and optimal long-term patency. Complex EVAR procedures can be performed percutaneously by accessing the EC directly under ultrasound guidance and using sequential dilation to avoid EC disruption.

A deformed Lunderquist wire in a percutaneous endovascular aortic aneurysm repair procedure

Introduction: An endovascular aortic aneurysm repair (EVAR) is a minimally invasive procedure for repairing an abdominal aneurysm. The advantage of this procedure is that EVAR does not require a laparotomy, hence reducing the physical insult to the body with a quicker recovery time for the patient. Percutaneous EVAR (PEVAR) involves accessing the femoral arteries percutaneously using an access needle without the need of a groin dissection. In this case, a guidewire was damaged and an emergency ‘cut down’ was required to repair the femoral artery. Case: An 85-year-old woman attended for an elective EVAR. The initial access was gained via percutaneous punctures to both her common femoral arteries under ultrasound guidance. On completion of the procedure the guidewire was removed with difficulty and an emergency right femoral dissection was performed and the common femoral artery was repaired. Postoperatively, the patient recovered well and was discharged the following day after observation. Discussion: In PEVAR there is no need to make an incision to dissect down to the vessels. Although the vascular closure device comes with an access wire, a standard wire can be passed through; in this case, a stiff wire was used. After removal of the guidewire from the right groin it was found that the wire was severely deformed. It is thought that the wire was caught in the calcium within the vessel. Conclusion: Although PEVAR is a common procedure, one must be mindful that many factors can affect the endovascular access and closure of the patient. The wire was damaged in this case, either in the femoral artery or in the closure device. It is paramount for vascular surgeons to anticipate that this could be a complication of PEVAR.

Use of EndoAnchors during index endovascular aortic aneurysm repair in patients with hostile proximal aortic neck anatomy.

Standard endovascular aortic aneurysm repair (EVAR) is sometimes the only treatment option for patients with hostile aortic neck anatomy, but it carries an increased risk of both early and late procedure-related complications. The aim of this study was to report on single-center experience with the Heli-FX EndoAnchors (Medtronic, Santa Rosa, CA) as an adjunctive procedure to endovascular aneurysm repair (EVAR) for prevention and perioperative treatment of proximal neck complications in patients with hostile neck anatomy. MATERIALS AND METHODS:Asingle-centre, retrospective study evaluating 24 consecutive patients treated with EndoAnchors during the index EVAR procedure between November 2018 and August 2021. EndoAnchor implantation was indicated for cases with hostile proximal aortic neck anatomy characterised by the presence of at least one of the following parameters: length of 28 mm, angle of >60°, circumferential thrombus/calcification involving ≥50%, and reverse taper. Median follow-up period was 22.5 months (IQR 2-31.5 months) with no aneurysm-related death, rupture, or conversion to open surgical repair during the follow-up. The procedural success rate was 100%, with no type Ia endoleak at the completion angiography. Amean of 7 EndoAnchors was used per patient (range 4-12). There were no EndoAnchor fractures and dislocations or stent graft fabric damage due to anchor implants.Twenty-three patients (95.8%) remained free of type Ia endoleak and migration on follow-up imaging. Aneurysm sac regression was observed in 13 patients (54.1%), while in 8 patients (33.3%) the sac remained stable. Sac enlargement was present in 1 patient (4.2%) due to late type Ia endoleak. Twopatients were lost to the follow-up immediately after the procedure.Between two groups of patients (sac regression versus failure to regress), the larger initial diameter of the proximal neck was the only significant independent factor associated with a lower possibility of sac regression (p= 0,021). The use of EndoAnchors during the index EVAR procedure in cases with challenging aortic neck anatomy with or without perioperative type Ia endoleak was associated with good midterm results and led to sac regression in most of the patients (Tab. 4, Fig. 3, Ref. 31).

A narrative review of intraoperative adjuncts and techniques to minimize radiation during complex endovascular aneurysm repair

BackgroundRadiation exposure is a known risk to both patients and providers during endovascular aortic aneurysm repair (EVAR). Complex EVAR procedures, such as fenestrated and branched EVAR, inherently involve longer fluoroscopy times and increased radiation doses. While adhering to the as low as reasonably achievable principles and ensuring appropriate personal protective equipment for all operating room staff remains essential, the use of intraoperative techniques and adjuncts to decrease radiation specifically during complex EVAR is necessary. This review aims to summarize intraoperative radiation reduction techniques to provide valuable insights to vascular surgeons and interventional proceduralists to enhance radiation safety during complex EVAR. MethodsThis review focused on intraoperative techniques and adjuncts that have been used to decrease intraoperative radiation exposure to patients and operators. Published and presented preclinical results, prospective and retrospective study data, and future directions are presented. ResultsWe highlight several intraoperative adjuncts and techniques for reducing radiation exposure during complex EVAR including image fusion, digital zooming, intravascular ultrasound examination, Fiber Optic RealShape (FORS) technology, and robotic navigation systems. Short-term outcomes suggest that these techniques are safe, feasible, and effective and decrease radiation exposure to both patients and operators. ConclusionsDecreasing radiation exposure during complex EVAR remains of critical importance. The presented techniques offer promising avenues for significantly decreasing radiation exposure to both patients and providers while maintaining procedural efficacy during complex EVAR.

Strategy for Totally Percutaneous Management of Vascular Injury in Combined Transfemoral Transcatheter Aortic Valve Replacement and Endovascular Aortic Aneurysm Repair Procedures

Minimally invasive treatment of severe aortic stenosis by transcatheter aortic valve replacement (TAVR) and infrarenal abdominal aortic aneurysm by endovascular aortic aneurysm repair (EVAR) requires large-bore vascular access. These percutaneous transfemoral interventions may be performed as a combined procedure, however, vascular injury may necessitate surgical vascular repair. We implemented a strategy designed to enable percutaneous vascular repair, with stent-graft implantation, if necessary, after these combined procedures. We identified all combined percutaneous TAVR and EVAR procedures which were performed at our institution. Patient and procedural characteristics and clinical outcomes were analyzed. Six consecutive patients underwent total percutaneous combined TAVR and EVAR procedures. In all cases, TAVR was performed first and was followed by EVAR. Both common femoral arteries served as primary access sites for delivery of the implanted devices and hemostasis was achieved by deployment of vascular closure devices. Secondary access sites included the right brachial artery in all patients and superficial femoral arteries in 50% of the patients. In all cases an "0.014" 300-cm length "safety" wire was delivered to the common femoral artery or descending aorta by way of a secondary access site to facilitate stent graft delivery. Successful device implantation was achieved in all cases. Vascular closure device failure occurred in 2 patients and was treated by stent graft implantation by way of the brachial and superficial femoral arteries, without need for surgical vascular repair. A strategy designed to facilitate percutaneous vascular repair after combined EVAR and TAVR procedures may enable a truly minimally invasive procedure.

Monte Carlo Dosimetry Validation for X-Ray Guided Endovascular Procedures

Endovascular treatment is continuously gaining ground in vascular surgery procedures. However, current patient radiation dose estimation does not take into account the exact patient morphology and organs' composition. Monte Carlo (MC) simulation can accurately estimate the dose by recreating the irradiation process generated during X-ray-guided interventions. This study aimed to validate the MC simulation models by comparing simulated and measured dose distributions in endovascular aortic aneurysm repair (EVAR) procedures. We conducted a clinical study in patients treated for EVAR. Patient dose measurements were taken with passive dosimeters using Optically Stimulated Luminescence technology in 4 specific anatomical points on the skin: xiphoid process, pubic symphysis, right and left iliac crest. Dose measurements were compared to the corresponding simulated doses with the Geant4 Application for Emission Tomography (GATE) and GPU Geant4-based Monte Carlo Simulations (GGEMS) MC simulations softwares. The MC simulation took as input the computed tomography scan of the patient and the parameters of the imaging system (orientation angles, tube voltage, and aluminum filtration) and gives as output the three-dimensional (3D) dose map for each patient and angulation. A good agreement with real doses was found for doses simulated by the MC GATE method (P<0.0001; r=0.97; 95% confidence interval [CI] [0.96-0.98]), as well as for doses simulated by the GGEMS method (P<0.0001; r=0.96; 95% CI [0.94-0.97]). The mean relative error for all measurements was 5±5% in the MC GATE group and 6±5% in the GGEMS group. Process execution on GGEMS (6sec) was faster than the GATE MC simulation (5hr). Considering the current imaging settings, this study shows the potential of using the GATE and GGEMS MC simulations platforms to model the 3D dose distributions during EVAR procedures.

PyMCGPU-IR Monte Carlo code test for occupational dosimetry.

PyMCGPU-IR is an innovative occupational dose monitoring tool for interventional radiology procedures. It reads the radiation data from the Radiation Dose Structured Report of the procedure and combines this information with the position of the monitored worker recorded using a 3D camera system. This information is used as an input file for the fast Monte Carlo radiation transport code MCGPU-IR in order to assess the organ doses, Hp(10) and Hp(0.07), as well as the effective dose. In this study, Hp(10) measurements of the first operator during an endovascular aortic aneurysm repair procedure and a coronary angiography using a ceiling suspended shield are compared to PyMCGPU-IR calculations. Differences in the two reported examples are found to be within 15%, which is considered as being very satisfactory. The study highlights the promising advantages of PyMCGPU-IR, although there are still several improvements that need to be implemented before its final clinical use.

High incidence of type 2 endoleak and low associated adverse events in the Vascular Quality Initiative linked to Medicare claims

IntroductionType 2 endoleak (T2EL) is the most common adverse finding on postoperative surveillance after endovascular aortic aneurysm repair (EVAR). A low rate of aneurysm-related mortality with T2EL has been established. However, the optimal management strategy and the efficacy of reintervention remain controversial. This study used data from the Vascular Quality Initiative linked to Medicare claims (VQI-Medicare) to evaluate T2LE in a real-world cohort. MethodsThis retrospective review of EVAR procedures in VQI-Medicare included patients undergoing their first EVAR procedure between 2015 and 2017. Patients with an endoleak other than T2EL on completion angiogram and those without VQI imaging follow-up were excluded. Patients without Medicare part A or part B enrollment at the time of the procedure or without 1-year complete Medicare follow-up data were also excluded. The exposure variable was T2EL, defined as any branch vessel flow detected within the first postoperative year. Outcomes of interest were mortality, reintervention, T2EL-related reintervention, post-EVAR imaging, and T2EL behavior including spontaneous resolution, aneurysm sac regression, and resolution after reintervention. The association of prophylactic branch vessel embolization (PBE) with T2EL resolution and aneurysm sac regression was also evaluated. ResultsIn a final cohort of 5534 patients, 1372 (24.7%) had an identified T2EL and 4162 (75.2%) did not. The median age of patients with and without T2EL was 77 and 75 years, respectively. There were no differences in mortality, imaging, reintervention, or T2EL-related reintervention at 3 years after the procedure for patients with T2EL. The aneurysm sac diameter decreased by 4 mm (range: 9-0 mm decrease) in the total cohort. Patients with inferior mesenteric artery-based T2EL had the smallest decrease in aneurysm diameter (median 1 mm decrease compared with 1.5 mm for accessory renal artery-based T2EL, 2 mm for multiple feeding vessel-based T2EL, and 4 mm for lumbar artery-based T2EL; P < .001). Spontaneous resolution occurred in 73.7% of patients (n = 809). T2ELs with evidence of multiple feeding vessels were associated with the lowest rate of spontaneous resolution (n = 51, 54.9%), compared with those with a single identified feeding vessel of inferior mesenteric artery (n = 99, 60.0%), lumbar artery (n = 655, 77.7%), or accessory renal artery (n = 31, 79.5%) (P < .001). PBE was performed in 84 patients. Patients who underwent PBE and were without detectable T2EL after EVAR had the greatest rate of sac regression at follow-up (7 mm decrease) compared with baseline. ConclusionsT2EL after EVAR is associated with high rates of spontaneous resolution, low rates of aneurysm sac growth, and no evidence of increased early mortality or reintervention. PBE in conjunction with EVAR may be indicated in some circumstances.

Endovascular infrarenal aortic aneurysm repair: Perhaps we've gone about it all wrong

Endovascular infrarenal aortic aneurysm repair: Perhaps we've gone about it all wrong

Spondylodiscitis due to transmitted mycotic aortic aneurysm or infected grafts after endovascular aortic aneurysm repair (EVAR): A retrospective single-centre experience with short-term outcomes

PurposeTo report the challenging therapeutic approach and the clinical outcome of patients with pyogenic spondylodiscitis transmitted due to infected retroperitoneal regions of primary infected mycotic aortic aneurysms (MAAs) or secondary infected aortic stent grafts after endovascular aneurysm repair (EVAR).MethodsBetween 2012 and 2019, all patients suffering from spondylodiscitis based on a transmitted infection after the EVAR procedure were retrospectively identified. Patient data were analysed regarding the time between primary and secondary EVAR infection and spondylodiscitis detection, potential source of infection, pathogens, antibiotic treatment, complications, recovery from infection, mortality, numeric rating scale (NRS), COBB angle and cage subsidence.ResultsFifteen patients with spondylodiscitis transmitted from primary or secondary infected aortic aneurysms after EVAR were included. The median follow-up time was 8 months (range 1–47). Surgery for spondylodiscitis was performed in 12 patients. In 9 patients, the infected graft was treated conservatively. MAAs were treated in 4 patients first with percutaneous aortic stent graft implantation followed by posterior surgery of the infected spinal region in a two-step procedure. Infection recovery was recorded in 11 patients during follow-up. The overall mortality rate was 27% (n = 4). The mean pain intensity improved from an NRS score of 8.4 (3.2–8.3) to 3.1 (1.3–6.7) at the last follow-up.ConclusionEVAR was used predominantly to treat primary infected MAAs. Secondary infected grafts were treated conservatively. Independent of vascular therapy, surgery of the spine led to recovery in most cases. Thus, surgery should be considered for the treatment of EVAR- and MAA-related spondylodiscitis.

Single Angio-Seal vascular closure device for transfemoral access exceeding 8F

BackgroundThis was a retrospective single-center evaluation for off-label use of a single Angio-Seal-VIP 8F vascular closure device (VCD) (Terumo Interventional Systems, Somerset, NJ, USA) for retrograde transfemoral arterial access exceeding 8F. MethodsBetween 2010 and 2018, in 32 consecutive patients (3 females; mean age 67±9; range 46–86 years) retrograde femoral access was performed in 48 groins for aortoiliac stent or stent graft implantations using 9-14F sheaths. For vascular closure, one single Angio-Seal™-VIP 8F was used. Procedural success, closure-related complications, and risk factors were retrospectively evaluated using patient characteristics, duplex-ultrasound, and contrast-enhanced computed tomography angiography (CTA). Receiver-operating-characteristics were used for statistical analysis. ResultsTechnical success for deployment of VCD was 100%. Visual inspection and duplex-ultrasound confirmed immediate hemostasis in 100%. Postinterventional CTA depicted major vascular access site complications in 6.3% (3/48 groins) requiring surgical treatment. A subgroup of 13 patients underwent surgical cut-down one day after VCD deployment as part of a two-staged complex endovascular aortic aneurysm repair procedure, allowing for visual assessment of prior used undersized Angio-SealTM. Patient's height (p=0.028) and severe access site calcifications (p=0.028) proved as predictors for one vessel occlusion and two pseudoaneurysms. Low body-mass-index (BMI) showed a non-significant trend. Sheath-size, common femoral artery depth, or body weight were not indicative for occurrence of complications. ConclusionsIn selected cases, without availability of appropriate VCDs, a single Angio-SealTM-VIP 8F served as a feasible option to achieve sufficient hemostasis of transfemoral access exceeding 8F without relevant bleeding complications. Very low BMI, tall body-height, and severe atherosclerosis were identified to predispose to access site complications.

IP065. Opioid Consumption Following Endovascular Repair of Abdominal Aortic Aneurysm

Opioid deaths continue to climb, with a record number of deaths of 13.3 per 100,000 people in 2016. Overprescription of opioids is a major contributor to this epidemic. Previous studies have identified over-prescription following general and vascular surgery procedures. The objective of this study is to evaluate the difference in opioids prescribed compared with opioids consumed following endovascular aortic aneurysm repair (EVAR). This is a retrospective review of the opioid prescribing habits following discharge from EVAR procedure. Patients who were documented to receive an opioid prescription were included in the study. A phone survey was conducted to determine patient consumption of the prescribed pills. The primary outcome is the difference between opioids prescribed and opioids consumed. Secondary analysis evaluates the difference in opioid consumption based on access type (percutaneous or open). There were 40 patients available for inclusion (Table). The mean age was 70.8 years with white (95%) males (75%) making up most patients. A total of 1185 pills were prescribed (29.6 ± 2.06 per patient), but only 208 pills consumed (5.2 ± 1.27 per patient; Fig). Eighty-two percent of total pills prescribed were not consumed. Of the 40 patients, 29 (73%) received bilateral percutaneous access. There were 669 pills remaining (79%) in the percutaneous group and 308 (90%) in the open group. These data are the first to compare opioid prescription with opioid consumption following EVAR. We demonstrate that patients consume much fewer opioids than prescribed. These findings add to the growing body of literature indicating that opioids are overprescribed following surgical procedures. Adoption of minimal access procedures should translate to cessation of discharge oral narcotic analgesics.TablePatient demographicsEVAR patients (n = 40)Mean% or SEPatient characteristics Male sex3075% Age, years70.81.28White3895%Opioids prescribed Total prescribed1185 Pills per patient29.62.06Opioids consumed Total consumed208 Pills per patient5.21.27 Pills consumed, %0%2358%25%1025%50%38%100%410% Refills requested211% Refills prescribed16%EVAR, Endovascular aortic aneurysm repair; SE, standard error. Open table in a new tab

Racial Disparities in Endovascular Aortic Aneurysm Repair

Racial and ethnic disparities are a critical issue in access to care within all fields of medicine. We hypothesized that analysis of a statewide administrative dataset would demonstrate disparities based on race with respect to access to this latest technology and the associated outcomes following endovascular aortic aneurysm repair (EVAR). Utilizing de-identified data from the Florida State Agency for Health Care Administration, we identified patients based on International Classification of Diseases Ninth Revision procedure codes who underwent EVAR between the years 2000 and 2014. We then assigned these procedures with the specialty of the operating physician and then analyzed outcomes based on the race of the patient. We identified 36,601 EVAR procedures during the study period. The average age of the total sample was 73.38 (±9.87), with the majority of the cohort being male (n=29,034, 81.2%). Breakdown of patients within each race category was as follows: 17,056 (47.7%) non-Hispanic Whites, 1,630 (4.6%) non-Hispanic African Americans, 16,431 (46.0%) Hispanics, and 632 (1.8%) patients identified as "other." Data analysis showed significant differences among age at presentation, sex of patient, and comorbidity score of patients at presentation. There were significant differences in outcomes based on race with respect to total hospital charges, length of stay, disposition, and payer status. Racial disparities were discovered with respect to EVAR treatment. African Americans present at younger ages, have the highest percentage of females requiring intervention, have the longest hospital stays, have the highest Medicaid payer source, have the highest in-hospital total charges of any racial group, and are more likely to be treated by academic practitioners. Hispanics present with the highest comorbidity scores compared to their counterparts and, along with African Americans, are more likely to be treated by nonvascular surgeons.

Prognostic Nomogram for Patients with Hostile Neck Anatomy after Endovascular Abdominal Aortic Aneurysm Repair

Since the introduction of endovascular aortic aneurysm repair (EVAR), the morphology of aneurysm neck has a great impact on prognosis of patients who underwent elective abdominal aortic aneurysm (AAA) repair. In this study, we aimed to analyze the morphologic features and prognosis after EVAR for patients with hostile neck anatomy and tried to create a novel prognostic nomogram in predicting EVAR-related adverse events. We retrospectively reviewed 812 patients with infra-renal AAA who underwent elective EVAR procedures between January 2010 and December 2015 at our single center and identified patients with hostile neck. Univariable and multivariable analyses were performed to determine the significant prognostic factors for EVAR-related adverse events, which were then integrated to build a nomogram. The model was subjected to bootstrap resamples for internal validation. The discriminative ability was presented with calibration plots and measured by concordance index (C-index) and area under the curve (AUC) from receiver-operating characteristic curve. The overall EVAR-related adverse events rate for 323 patients with hostile neck was 12.1%. By multivariable analysis, significant risk factors of adverse events included female (odds ratio [OR], 2.58; 95% confidence interval [CI], 1.18-5.62; P=0.017), conical neck (OR, 4.66; 95% CI, 1.5-14.51; P=0.008), short neck (OR, 2.71; 95% CI, 1.49-4.94; P=0.001), and angulated neck (OR, 3.26; 95% CI, 1.43-7.43; P=0.005). A nomogram was developed based on the results of multivariable analysis. Calibration plots presented an excellent agreement between model predicted and actually observed risk of adverse events after internal validation. The discrimination ability of this risk predictive model was reasonable (C-index=0.79; AUC=0.81, 95% CI, 0.73-0.89). EVAR is a feasible and safe treatment for most of patients with hostile neck. We developed and validated a novel model for predicting the risk of adverse events after EVAR and clarified high-risk patients.

Predicting failure to rescue after abdominal aortic aneurysm repair in elderly patients

BackgroundWe aim to describe trends in failure to rescue (FTR) among elderly patients undergoing elective open aortic aneurysm repair (OAR) and endovascular aortic aneurysm repair (EVAR). Materials and methodsAll patients aged ≥80 y recorded in the Vascular Quality Initiative database (2002-2014) undergoing nonruptured infrarenal AAA repair were included. Primary outcome was FTR, defined as percentage of deaths in patients who had a complication within 30 d of surgery. Univariable and multivariable statistics were used to identify risk factors for FTR following OAR and EVAR procedures. Results975 elderly patients underwent AAA repair during the study period (EVAR = 667, OAR = 308). Overall FTR was 10%, most commonly related to acute kidney injury (62%) and respiratory failure (53%). Independent predictors of FTR included female gender (odds ratio [OR] 1.95), multiple comorbidities (OR 1.98), renal insufficiency (OR 1.97), peripheral vascular disease (OR 2.42), and perioperative vasopressor use (OR 4.49) (all, P < 0.02). Obesity was protective (OR 0.58, P = 0.02). FTR was higher following OAR versus EVAR (14% versus 9%; P = 0.02) on univariable analysis, but there was no significant difference between operative approaches after risk adjustment (OR 1.15, P = 0.60). Comparing elderly versus younger patients (n = 2854), FTR was significantly higher for the elderly for both OAR (OR 2.0, 95% CI 1.36-3.01) and EVAR (OR 1.60, 95% CI 1.07-2.40). ConclusionsFTR after AAA repair is not uncommon among elderly patients and could explain the higher mortality observed in this group compared to the general population. Overall health status should be carefully considered when weighing the risks versus benefits of performing AAA repair in patients aged ≥80 y.

PC092 Prospective Validation of High-Fidelity Simulation of Endovascular Aortic Aneurysm Repair Using 3D Printed Aortic Model and Fluid Pump

This study investigated the feasibility of endovascular aortic aneurysm repair (EVAR) training using high-fidelity simulation with a three-dimensional (3D) printed aortic model connected to hemodynamic pump. The study was a prospective validation of EVAR simulation using a 3D printed photopolymer aortic model (Objet500 Connex3 printer; Stratasys, Eden Prairie, Minn) connected to BDC PD-0500 fluid pump (BDC Laboratories, Wheat Ridge, Colo). EVAR procedure metrics were benchmarked in two expert implanters and compared to 20 vascular surgical trainees with different levels of EVAR experience (<20 or >20 cases). All procedures were performed using commercially available stent grafts, fluoroscopic guidance, and high-fidelity simulation of procedural steps with guidewires, catheters, and contrast angiography (Fig). End points included ability to complete the procedure independently and time to deploy aortic component, cannulate the contralateral (CL) gate and complete the repair, total fluoroscopy time, and estimated distance from lowest renal artery. Trainee experience with EVAR prior to the first simulation session was fewer than 5 in 7 trainees, 6 to 20 in 6 and 20 in 7. A total of 22 EVAR simulation procedures were performed by trainees with mean total procedure time of 37 ± 12 minutes. Experienced trainees had significantly (P < .003) lower total procedural time (32 ± 9 vs 44 ± 6 minutes), fluoroscopic time (13 ± 5 vs 23 ± 8 minutes), and lag time between steps (5 ± 2 vs 7 ± 2 minutes). All experienced trainees completed the procedure independently in <45 minutes, compared to six (46%) of those with less EVAR experience (P = .016). Among less experienced trainees, only two (15%) completed the entire procedure independently (P < .001). Expert implanters performed significantly better than both trainee groups in nearly all EVAR metrics (Table). EVAR simulation with 3D printed aortic models and hemodynamic pump was feasible and simulated all procedural steps with high fidelity. This model may be applicable for assessment of technical competencies and standard endovascular skill acquisition within vascular surgery training curricula.TableAnalyzed variables according to each groupaVariablebGroup 1 (n = 13)Group 2 (n = 7)Group 3 (n = 2)P valueP valueGroup 1 vs 2Complete main body deployment33 ± 625 ± 85 ± 2<.001.02Contralateral gate cannulation9 ± 77± 50 ± 0.2.6Contralateral limb deployment34 ± 626 ± 107 ± 1<.001.07Total time44 ± 632 ± 99 ± 0<.001.003Fluoroscopy time, min23 ± 813 ± 55 ± 0.1.001.005Completed independently2 (15)7 (100)2 (100)<.001<.001Finished <45 minutes6 (46)7 (100)2 (100)0.029.02aGroup 1, less experienced trainees (with <20 endovascular aneurysm [EVAR] cases of experience); group 2, more experienced trainees (with >20 EVAR cases of experience); group 3, benchmarks/experienced EVAR implanters.bData are shown as mean ± standard deviation or number (%). Open table in a new tab

Radiation Exposure in Endovascular Infra-Renal Aortic Aneurysm Repair and Factors that Influence It.

ObjectiveThe endovascular repair of aortic abdominal aneurysms exposes the patients and surgical team to ionizing radiation with risk of direct tissue damage and induction of gene mutation. This study aims to describe our standard of radiation exposure in endovascular aortic aneurysm repair and the factors that influence it.MethodsRetrospective analysis of a prospective database of patients with abdominal infra-renal aortic aneurysms submitted to endovascular repair. This study evaluated the radiation doses (dose area product (DAP)), fluoroscopy durations and their relationships to the patients, aneurysms, and stent-graft characteristics.ResultsThis study included 127 patients with a mean age of 73 years. The mean DAP was 4.8 mGy.m2, and the fluoroscopy time was 21.8 minutes. Aortic bilateral iliac aneurysms, higher body mass index, aneurysms with diameters larger than 60 mm, necks with diameters larger than 28 mm, common iliac arteries with diameters larger than 20 mm, and neck angulations superior to 50 degrees were associated with an increased radiation dose. The number of anatomic risk factors present was associated with increased radiation exposure and fluoroscopy time, regardless of the anatomical risk factors.ConclusionThe radiation exposure during endovascular aortic aneurysm repair is significant (mean DAP 4.8 mGy.m2) with potential hazards to the surgical team and the patients. The anatomical characteristics of the aneurysm, patient characteristics, and the procedure's technical difficulty were all related to increased radiation exposure during endovascular aortic aneurysm repair procedures. Approximately 40% of radiation exposure can be explained by body mass index, neck angulation, aneurysm diameter, neck diameter, and aneurysm type.