Endovascular Aneurysm Repair Research Articles

Safe and favorable prognosis of thoracic endovascular aortic repair for the low-risk patients with non-acute type B aortic dissection

ObjectivePreemptive thoracic endovascular aortic repair (TEVAR) has the potential to improve the prognosis of Stanford type B aortic dissection (TBAD), however it is important to determine whether it could be safely performed as a prophylactic treatment. This study aimed to determine the short- and long-term outcomes of preemptive TEVAR for uncomplicated TBAD with a small aortic aneurysm.DesignRetrospective multicenter analysis.MethodsWe analyzed 212 patients with medically treated uncomplicated subacute TBAD between July 2004 and October 2019 in two Japanese academic centers. The short- and long-term prognosis of patients who underwent preemptive TEVAR and the changes in aortic diameter over time after TEVAR were analyzed. Aorta-related complications, aortic-related death and postoperative complications were recorded and analyzed. Analysis was performed on an intension-to-treat basis.ResultsDuring follow-up, patients were divided into two groups: optimal medical treatment [OMT; n = 185 (87%)] and preemptive TEVAR [n = 27 (13%)]. In all cases, aortic enlargement was the reason for therapeutic intervention in the preemptive TEVAR group. Propensity score matching yielded a cohort of 27 control patients with OMT (group A) and 27 patients who underwent preemptive TEVAR (group B). Preoperative characteristics were similar between groups. In group B, only one patient developed type A dissection at a late stage and died from aortic rupture. Freedom from aortic-related death at 1/5/10 years was 100%/92%/92% in group B. Overall growth (mm/year) of max aorta was significantly smaller in the TEVAR group than in the control group (−3.7 ± 2.9 vs. 0.4 ± 5.6, p < 0.01), and the diameter of the false lumen was reduced (−8 ± 4.8 vs. −1.3 ± 8.0, p < 0.001).ConclusionsShort- and long-term outcomes of TEVAR for uncomplicated TBAD with a small aortic aneurysm were excellent, with few postoperative complications. After TEVAR, aortic remodeling was observed in the short term, suggesting that it may contribute to the prevention of aortic-related death due to rupture.

Variation in care in individuals hospitalised with abdominal aortic aneurysm in nine high-income countries: a cross-sectional cohort study

Abstract Background Abdominal aortic aneurysms (AAA) can be safely repaired using either endovascular aneurysm repair (EVAR) or open repair when intact, but after rupture morbidity and mortality are extremely high. Treatment patterns and outcomes for intact AAA are likely to differ between countries due to differences in AAA screening policies, health system capacity and payment approaches, and other factors, such as demographics and lifestyle, but are poorly studied. Methods We conducted a retrospective serial cross-sectional cohort study of adults aged ≥66 years hospitalised for with an intact AAA and repair procedure in the same admission between 2011 and 2019 in nine countries (US, Canada, England, Denmark, Netherlands, Switzerland, Taiwan, South Korea and Israel) using population-representative administrative data. We investigated age-sex standardised (to the 2019 US population) repair rates (open repair or EVAR) and health system performance measures, including hospital length of stay (LOS), 30-day readmission, and all-cause mortality (30 days and 1 year). Results The number of intact AAA hospital admissions between 2011 and 2019 ranged from 1,290 in Israel to 199,764 in the US. The rates of intact AAA repair per 1000 population varied between countries and over time, from 0.11 per 1000 (South Korea) to 0.69 per 1000 (US) in 2011 and from 0.14 per 1000 (Taiwan) to 0.57 per 1000 (the Netherlands) in 2019. Most countries saw a decline in the rate of AAA repair over the study period. The proportion repaired using open repair vs EVAR also varied widely across the countries. In the US, Israel and Taiwan open repair was used in 11% or fewer cases whereas in the remaining countries we observed open repair in 25.1 % (South Korea) to 56.7% (Denmark) of cases. (Figure 1) Mortality was generally higher following open repairs compared to EVAR in all countries. In 2019, following EVAR, 30-day mortality varied from 0.6% (8.1% at 1 year) in South Korea to 2.3% (11.7% at 1 year) in Israel and following open repair varied from 2.9 (4.4% at 1 year) in England to 7.6% (15.1% at 1 year) in the US. (Figure 2) Mean hospital LOS in 2019 ranged from 2.5 days (US) to 12.2 days (South Korea), following EVAR and from 9.1 days (Taiwan) to 21.5 days (South Korea) following open repair. The 30-day readmission rate in 2019 ranged from 8.1% (US) to 31.8% in Israel following EVAR and from 11.4% (US) to 22.2% (South Korea) following open repair. Conclusions We observed substantial between-country variation in surgical approaches, mortality, and health system performance measures for AAA. Further research is needed to understand and plan optimal, evidence-based AAA screening and treatment strategies.Rates of EVAR and open repairAdjusted 30-day all-cause mortality

Transmission line model as a digital twin for abdominal aortic aneurysm patients

We investigated the potential of the transmission line model as a digital twin of aneurysmal aorta by comparatively analyzing how a uniform lossless tube-load model were fitted to the carotid and femoral artery tonometry waveforms pertaining to (i) 79 abdominal aortic aneurysm (AAA) patients vs their matched controls (CON) and (ii) 35 AAA patients before vs after endovascular aneurysm repair (EVAR). The uniform lossless tube-load model fitted the tonometry waveforms pertaining to AAA as well as CON and EVAR. In addition, the parameters in the tube-load model exhibited physiologically explainable changes: when normalized, both pulse transit time and reflection coefficient increased with AAA and decreased after EVAR, which can be explained by the increase in arterial compliance and the decrease in arterial inertance due to the aortic expansion associated with AAA. In sum, the tube-load model may have the potential as a digital twin to enable personalized AAA monitoring.

Antegrade in-situ needle assisted fenestration during thoracic endovascular aortic repair for preserving left subclavian artery.

Antegrade in-situ needle assisted fenestration during thoracic endovascular aortic repair for preserving left subclavian artery.

Simultaneous versus staged approach in transcatheter aortic valve implantation for severe stenosis and endovascular aortic repair for thoracic and abdominal aortic aneurysm.

Thoracic/abdominal aortic aneurysms(T/AAAs) and aortic stenosis(AS) may be concomitant diseases requiring both transcatheter aortic valve implantation(TAVI) and endovascular aneurysm repair(T/EVAR) in high risk patients for surgical approaches, but temporal management is not clearly defined, yet. Aim of the study was to analyze outcomes of simultaneous vs staged TAVI and T/EVAR. Retrospective observational multicentre study on patients requiring TAVI and T/EVAR from 2016 to 2022. Patients were divided into 2 groups: "Simultaneous group" if T/EVAR+TAVI were performed in the same procedure and "Staged group" if T/EVAR and TAVI were performed in two steps, but within 3 months. Primary outcomes were: technical success, 30-day mortality/major adverse events and follow-up survival. Secondary outcomes were procedural metrics and length of stay (LOS). Forty-four cases were collected; 8(18%) had TEVAR and 36(82%) EVAR, respectively. Upon temporal determination 25(57%) and 19(43%) were clustered in simultaneous and staged groups, respectively. In staged group, median time between procedures was 72(interquartile-range-IQR : 57-87) days. Preoperative and intraoperative figures were similar. There was no difference in 30-day mortality(Simultanoeus : 0/25 vs Staged : 1/19; p = 0.43). Pulmonary events(Simultaneous : 0/25 vs Staged : 5/19; p = 0.01) and need of postoperative cardiac pacemaker(Simultaneous : 2/25 vs Staged : 7/19; p = 0.02) were more frequent in Staged patients. The overall LOS was lower in Simultaneous group[Simultaneous : 7(IQR : 6-8) vs Staged : 19(IQR : 15-23)days; p = 0.001]. The median follow-up was 25(IQR : 8-42) months and estimated 3-year survival was 73% with no difference between groups(Simultanoeus : 82% vs Staged : 74%; p = 0.90). Both simultaneous or staged T/EVAR and TAVI procedures are effective with satisfactory outcomes. Despite the small numbers, simultaneous repair seems to reduce length-of-stay and pulmonary complications, maintaining similar follow-up survival.

Large bore access for transcatheter aortic valve replacement, endovascular aortic repair, and thoracic endovascular aortic repair. A review of anatomic challenges and operative considerations.

Transcatheter aortic valve replacement (TAVR), endovascular aortic repair (EVAR), and thoracic endovascular aortic repair (TEVAR) are standard and prolific procedures in the modern cardiovascular world, and appropriate delivery of these endoprostheses requires adequate understanding of the requisite large bore access. Percutaneous large bore access is the preferred route but may be accompanied by complications like thrombosis, hemorrhage, or inability to deliver the device. Anatomic limitations such as vessel tortuosity, small size, and heavy calcification may require alternative approaches for successful large bore access. This study aimed to better define large bore access, as well as to elucidate optimal adjuncts and alternatives to enable successful delivery of large bore endoprostheses. A systematic review for "large bore access" in the cardiovascular literature was conducted on PubMed and the Cochrane Library Central according to PRISMA guidelines. Identified articles were filtered and sub-selected for TAVR, EVAR, and TEVAR; studies related to other large bore interventions were excluded. A representative selection of 39 full-text studies included both cardiac and vascular studies and was critically interpreted to identify a consensus definition for large bore access, challenging anatomy, and adjuncts or alternative approaches to the standard transfemoral approach. Transfemoral access remains the first-line approach but in the setting of unfavorable anatomy, adjunct maneuvers (e.g. intravascular lithotripsy, endoconduits) or alternative approaches (supra-aortic, transcaval) help decrease morbidity, mortality, length of procedure, and overall health care cost in large bore access.

Early and Late Aortic-Related Mortality and Rupture After Fenestrated-Branched Endovascular Aortic Repair of Thoracoabdominal Aortic Aneurysms: A Prospective Multicenter Cohort Study.

Fenestrated-branched endovascular aortic repair (FB-EVAR) has been used as a minimally invasive alternative to open surgical repair to treat patients with thoracoabdominal aortic aneurysms (TAAAs). The aim of this study was to evaluate aortic-related mortality (ARM) and aortic aneurysm rupture after FB-EVAR of TAAAs. Patients enrolled in 8 prospective, nonrandomized, physician-sponsored investigational device exemption studies between 2005 and 2020 who underwent elective FB-EVAR of asymptomatic intact TAAAs were analyzed. Primary end points were ARM, defined as any early mortality (30 days or in hospital) or late mortality from aortic rupture, dissection, organ or limb malperfusion attributable to aortic disease, complications of reinterventions, or aortic rupture. Secondary end points were early major adverse events, TAAA life-altering events (defined as death, permanent spinal cord injury, permanent dialysis, or stroke), all-cause mortality, and secondary interventions. A total of 1109 patients were analyzed; 589 (53.1%) had extent I-III and 520 (46.9%) had extent IV TAAAs. Median age was 73.4 years (interquartile range, 68.1-78.3 years); 368 (33.2%) were women. Early mortality was 2.7% (n=30); congestive heart failure was associated with early mortality (odds ratio, 3.30 [95% CI, 1.22-8.02]; P=0.01). Incidence of early aortic rupture was 0.4% (n=4). Incidence of early major adverse events and TAAA life-altering events was 20.4% (n=226) and 7.7% (n=85), respectively. There were 30 late ARMs; 5-year cumulative incidence was 3.8% (95% CI, 2.6%-5.4%); older age and extent I-III TAAAs were independently associated with late ARM (each P<0.05). Fourteen late aortic ruptures occurred; 5-year cumulative incidence was 2.7% (95% CI, 1.2%-4.3%); extent I-III TAAAs were associated with late aortic rupture (hazard ratio, 5.85 [95% CI, 1.31-26.2]; P=0.02). Five-year all-cause mortality was 45.7% (95% CI, 41.7%-49.4%). Five-year cumulative incidence of secondary intervention was 40.3% (95% CI, 35.8%-44.5%). ARM and aortic rupture are uncommon after elective FB-EVAR of asymptomatic intact TAAAs. Half of the ARMs occurred early, and most of the late deaths were not aortic related. Late all-cause mortality rate and the need for secondary interventions were 46% and 40%, respectively, 5 years after FB-EVAR. URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02089607, NCT02050113, NCT02266719, NCT02323581, NCT00583817, NCT01654133, NCT00483249, NCT02043691, and NCT01874197.

Blunt Thoracic and Abdominal Aortic Injury in Multiple Trauma: A Case Report.

Blunt abdominal aortic injury (BAAI) is rare among traumatic aortic injuries, and further complications of blunt thoracic aortic injury (BTAI) have never been reported. A man in his 80s presented to our hospital following a motor vehicle accident. Pan-scan contrast-enhanced CT showed a thoracic aortic isthmus injury (Grade III), an abdominal aortic injury (Grade IV) with extravasation of contrast media at the level of the fourth lumbar vertebra. Endovascular abdominal aortic repair was performed on the same day and a thoracic endovascular aortic repair for BTAI was performed 11 days after admission. The patient had a good postoperative course and was discharged without complications. This report presented a rare case of BTAI complicated with BAAI. The timing of intervention for aortic injury should be determined based on urgency and other organ damage.

Long-Term Outcomes of PETTICOAT Technique-Assisted Thoracic Endovascular Aortic Repair for the Treatment of Acute and Subacute Complicated Type B Aortic Dissection.

To evaluate the long-term outcomes of the provisional extension to induce complete attachment technique (PETTICOAT) for the treatment of acute and subacute complicated type B aortic dissection (TBAD). We retrospectively collected and analyzed the clinical data of patients with acute and subacute TBAD who were treated using the PETTICOAT technique at our center between March 2014 and March 2023. The primary endpoint was all-cause mortality; secondary endpoints were a composite of complications, such as entry flow, stent-graft-induced new entry (SINE), and re-intervention. The technical success was 92% (46/50). The perioperative mortality was 2% (1/50), and the procedure-related re-intervention was also 2% (1/50). The mean follow-up time was (74.9±33.9) months. The mortality was 4.1% (2/49). The incidence of aortic-related complications was 8.2% (4/49), including new entry flow, 2 retrograde type A aortic dissections, and 1 distal stent graft-induced new entry SINE. The procedure-related re-intervention rate was 4.1% (2/49). After 5 years of follow-up, the total aortic diameter at the renal artery level was reduced from that at the third year of follow-up but was still significantly larger than preoperatively (26.9±6.6 mm vs. 24.1±4.2 mm, p=0.013). While at the covered stent, bare stent, stentless, and celiac artery (CA) levels, the total aortic diameters did not change significantly compared with preoperative values, whereas true lumen (TL) diameters and TL ratios were maintained at obviously higher levels than preoperative. The rate of complete thrombosis of false lumen in the thoracic aortic segment was significantly higher than that in the abdominal aortic segment (79.6% vs 30.6%, p=0.0001). The results indicated that the PETTICOAT technique is safe and effective and could promote positive remodeling of the aorta from the level of the covered stent to the CA. Remodeling of the distal abdominal aorta may fluctuate and requires close follow-up review. The long-term results from our center suggest that the PETTICOAT technique promotes positive remodeling of the aorta from the level of the covered stent to the CA; whereas this advantage does not seem to be significant in the more distal segment of the abdominal aorta, mainly at the level of RA and distal. Therefore, further procedures may be required for aortic dissection of the abdominal segment. In addition, aortic remodeling may fluctuate to some extent during the follow-up period, especially in the abdominal visceral region, so close follow-up review is quite important, and prompt re-intervention is required if necessary.

Ruptured Complex Aortoiliac Aneurysm in an Elderly Patient With a Kidney Transplant Presenting With Sciatica.

Background: Common iliac artery aneurysms are uncommon, with an estimated incidence of less than 0.01% in adults and accounting for only 1% of all intra-abdominal aneurysms. While the risk of rupture is approximately 5%, it increases significantly to 29% once the aneurysm reaches 4 cm. Similarly to abdominal aortic aneurysms, common iliac artery aneurysms often develop silently, remaining asymptomatic in about 70% of cases. This report describes the treatment of a patient with a kidney transplant who underwent endovascular repair of a ruptured left common iliac artery aneurysm with a concomitant abdominal aortic aneurysm and a focal aneurysm of the right renal artery origin. Case Description: A 78-year-old male patient with a kidney transplant presented with left sciatica symptoms and was found to have a contained rupture of a 10 x 7 cm left common iliac artery aneurysm with a concomitant 8 cm abdominal aortic aneurysm and a focal 1.8 cm aneurysm of the right renal artery origin. He underwent an endovascular aneurysm repair with an Aorto-Uni-iliac stent graft and a concomitant right-to-left femoral-femoral bypass using 8 mm ringed PTFE graft and ligation of left external iliac artery to prevent retrograde flow into the left common iliac artery aneurysm. At 3-year follow-up, patient remains stable with a functioning kidney transplant and excluded aneurysms with no evidence of endoleak. Conclusion: This report describes the endovascular repair of a ruptured left common iliac artery aneurysm conducted under local anesthesia in a patient with a renal transplant and complex aneurysm anatomy. The calcification pattern observed on a non-contrast CT scan was effectively used for surgical planning, leading to a successful aneurysm repair while preserving kidney transplant function.

A stented elephant trunk procedure with retrograde cerebral perfusion for a rare type of pseudoaneurysm with an aberrant right subclavian artery.

Aberrant right subclavian artery (ARSA) is a rare congenital vascular anomaly that increases the risk of aortic dissection (AD). Although several treatment options for cases of AD with ARSA have been proposed, such as traditional surgery, thoracic endovascular aortic repair, and a hybrid procedure, a consensus regarding the optimal treatment strategy has not yet been established. And there are no reported cases of pseudoaneurysm combined with ARSA. A 44-year-old male was admitted with a 7-days history of chest pain. A physical examination was almost normal. Computed tomography angiography (CTA) showed an ARSA arose from the distal aortic arch and pseudoaneurysm located distal to the origin of the ARSA. The stented elephant trunk (SET) procedure with retrograde cerebral perfusion (RCP) was performed under moderate hypothermic circulatory arrest. The postoperative CTA demonstrated a well-perfused ARSA, left subclavian artery (LSA), left common carotid artery (LCCA), and right common carotid artery (RCCA), and occluded pseudoaneurysm with no endoleaks. He was discharged on postoperative day 9 and was doing well during his 6-months follow-up. With a smaller incision, a simple cannulation method, shorter surgical and circulatory arrest times, fewer blood transfusion requirements, and effective brain protection, the SET procedure with RCP can be a safe and feasible treatment option for complicated aortic arch anomalies with ARSA.

Clinical application of n-butyl-2- cyanoacrylate（NBCA） in the transarterial embolization for type I/II endoleak during and after EVAR surgery

Exploring the effectiveness and safety of n-butyl-2-cyanoacrylate (NBCA) in the transarterial embolization for common endoleak during and after endovascular repair of aortic aneurysm (EVAR). A total of 226 patients with abdominal aortic aneurysm (AAA) were treated with EVAR in 4 years August 2019 to February 2023, including 46 patients with ruptured aneurysms (rAAA). Account 37 cases developed endoleak during EVAR surgery and follow-up period, 28 non-ruptured AAA patients and 9 rAAA patients, then treated with NBCA for transarterial embolization. Follow up for at least six months to observe its clinical efficacy and adverse reactions. Among 37 cases of endoleak, there were eight cases of primary type Ia endoleak and one cases of primary right type Ib endoleak in the rAAA group, one case of primary type Ib endoleak, two cases of secondary type Ia endoleak and 25 cases of Postoperative type II endoleak in the non-ruptured AAA group. Three patients with primary type Ia endoleak were treated with coil assisted NBCA in the rAAA group, while the remaining 34 patients with type I and type II endoleaks were treated with NBCA alone. All transarterial embolization achieved technical success and the endoleak disappeared. Postoperative hospitalization observation showed that three cases patients in the rAAA group who experienced primary type Ia endoleak during emergency EVAR surgery died within 4 days after surgery due to hemorrhagic shock and multiple organ failure. Two patients experienced non-AAA related deaths during the follow-up period. Transartrial embolization with NBCA for the treatment of primary and secondary endoleak is a safe and effective method. It can achieve more dense embolization of the aneurysm sac and more complex endoleaks embolization. And it showed a low recurrence rate of endoleak and the incidence of perioperative complications after surgery, which is worthy of clinical promotion and application. Even in emergency EVAR combined with primary type I endoleak treatment in rAAA patients, patients can still benefit.

Early and Midterm Outcomes of Chimney Endovascular Aortic Repair for Ruptured Abdominal Aortic Aneurysms.

To compare the outcomes of endovascular aortic aneurysm repair using a chimney technique (ch-EVAR) with those of the standard EVAR (st-EVAR) for ruptured abdominal aortic aneurysms (RAAA). We implemented ch-EVAR for juxtarenal RAAA based on obvious anatomical indications after converting the strategy for RAAA from open repair to EVAR. A retrospective, cohort-based study was conducted on patients with RAAA who were treated using EVAR in our hospital between July 2011 and March 2022. EVAR cases were extracted, and outcomes were compared between ch-EVAR and st-EVAR. Patient clinical status, anatomical variables, treatment, and follow-up data were evaluated. A total of 56 (82%) and 12 (18%) patients were treated by st-EVAR and ch-EVAR, respectively. Thirty-day mortality rates were comparable between the 2 groups [8.9% in st-EVAR vs 8.3% in ch-EVAR (p= 0.95)]. Short-term outcomes showed that no type Ia endoleak occurred in either group. Midterm outcomes, including sac enlargement [7.5% in st-EVAR vs 0% in ch-EVAR (p= 0.37)], shrinkage [77.5% in st-EVAR vs 80.0% in ch-EVAR (p= 0.86)], and overall survival and freedom from aneurysm-related reintervention at 3 years [64.7% and 96.4% in the EVAR group vs 91.7% and 100% in the ch-EVAR group, respectively (p= 0.30 and 0.52)], were not significantly different between the 2 groups. Ch-EVAR for RAAA showed remarkably excellent outcomes, comparable to those of st-EVAR. Ch-EVAR is considered technically feasible in experienced centers. The indications for EVAR for RAAA may be further expanded using the chimney technique, resulting in overall improved outcomes for RAAA. This is a retrospective, single-center analysis of 68 patients with ruptured abdominal aortic aneurysms (RAAAs) treated by endovascular repair (EVAR) to investigate the efficacy of the chimney technique for juxtarenal RAAA. Thirty-day mortality rate was 8.3% for the chimney EVAR group, which was equivalent to that in the standard EVAR group. Mid-term outcomes including sac enlargement/shrinkage, overall survival, and freedom from aneurysm-related reintervention were comparable between the two groups. This report suggests the possibility of broadening the selection criteria of the current endovascular strategy using the chimney technique.

Impact of Significant Sac Shrinkage on Endograft Tortuosity at 5 Years Post-EVAR: A Retrospective Analysis

Significant sac shrinkage after endovascular aortic aneurysm repair (EVAR) is generally considered a positive outcome indicative of durable clinical success. However, its impact on endograft configuration is rarely addressed. Sac remodeling and volume loss due to shrinkage can potentially cause deformation of endograft components, resulting in limb angulation and compression. We investigated the hypothesis that significant sac shrinkage could affect endograft tortuosity at 5 years post-EVAR. We retrospectively reviewed patients who underwent elective EVAR for infrarenal abdominal aortic aneurysm between June 2007 and December 2018. Patients with early postoperative and 5-year follow-up CT images were included. Patients treated with modular bifurcated endografts (Zenith, Endurant, Excluder, and Incraft) were analyzed. The "shrinkage" group comprised patients with >10mm diameter reduction, while the "stable" group had ±5mm diameter change at 5 years. Tortuosity index (TI) was calculated as the ratio of centerline distance to straight-line distance between proximal and distal endograft edges. The association between sac shrinkage and ≥5% increase of TI (≥5%ΔTI) was analyzed for both ipsilateral and contralateral sides. Of 136 patients enrolled, 80 were in the shrinkage group and 56 in the stable group. On the ipsilateral side, ≥5%ΔTI was observed in 24 cases (17.6%). Patients with ipsilateral ≥5%ΔTI had significantly shorter median neck lengths (22mm vs 30mm, p = 0.030). Sac shrinkage ≥15mm was negatively associated with ≥5%ΔTI compared to stable sac (p = 0.027). Logistic regression showed sac shrinkage ≥15mm had a significant negative correlation with ≥5%ΔTI (p = 0.025, HR [95% CI] 0.218 [0.057-0.824]). On the contralateral side, ≥5%ΔTI (19 cases, 14.0%) was associated with shorter neck length but not with sac shrinkage. In the shrinkage group, cross-leg positioning resulted in a significant increase in ipsilateral TI at 5 years compared to straight positioning (median ΔTI: 1.8% vs 0.0%, p = 0.013). No reinterventions for leg-related events were necessary during the 5-year follow-up period. Contrary to our initial hypothesis, significant sac shrinkage does not adversely affect endograft configuration and may help stabilize tortuosity on the ipsilateral side. However, in patients with crossed-leg configuration, continued vigilant observation may be warranted even after achieving sac shrinkage, as it could exacerbate tortuosity. Shorter neck length was associated with increased tortuosity on both sides. Further research is needed to confirm these findings and consider potential confounding factors, including the impact of different endograft designs.

Effects of Chronic Obstructive Pulmonary Disease on the Outcomes of Fenestrated-Branched Endovascular Aortic Aneurysm Repair.

Chronic obstructive pulmonary disease (COPD) is common in patients with aortic aneurysms. Severe COPD is associated with an increased risk of aneurysm rupture and perioperative complications. This study assesses the outcomes of COPD and non-COPD patients after fenestrated-branched endovascular aortic aneurysm repair (FBEVAR). A single institution, retrospective study of FBEVAR patients between 2011 and 2020 compared outcomes between COPD and non-COPD patients. COPD patients were stratified by Global Initiative for Chronic Obstructive Lung Disease criteria and oxygen dependence. Outcome measures included 30-day mortality, pulmonary complications, major adverse events (MAE), and mid-term survival. 387 patients (71% male, age 72 years, interquartile range [68-79]) underwent FBEVAR. 181 patients (47%) had COPD. Smoking history was more frequent in COPD patients (P = .022). Among COPD patients, 20.4% were oxygen-dependent. Technical success, defined as successful delivery of the main aortic endograft and all intended side branches, was 98.4%. 30-day mortality (P = .83) and MAE rates (P = .87) were similar between groups. While not statistically significant, COPD patients had more frequent pulmonary complications (6.1% vs. 2.4%, P = .13) and were more frequently discharged on oxygen (P = .002). There were no differences in intensive care unit or hospital length of stay between groups (P = .29; P = .85, respectively). 5-year survival was similar between groups (P = .10). Oxygen-dependent COPD and severe-very severe COPD were associated with decreased mid-term survival (Hazard Ratio 2.39, P = .048). FBEVAR is safe and effective for treating complex aortic pathology in COPD patients, including oxygen-dependent patients. Patients with more severe COPD were more frequently discharged on oxygen. Mid-term survival was slightly reduced in patients with oxygen-dependent and severe-very severe COPD. Level 3, non-randomized controlled cohort/follow-up study.

Routine Use of Indwelling Urinary Catheters During Endovascular Abdominal Aortic Aneurysm Repair is Not Necessary.

Endovascular infra-renal abdominal aortic aneurysm repair (EVAR) has proven to be an effective, less invasive alternative to open aortic aneurysm repair with decreased 30-day mortality. Historically, urinary drainage catheters were routinely placed preoperatively before EVAR in our institution. A shift to reduced catheter placement has occurred in conjunction with percutaneous EVARs becoming more routine. Urethral catheterization carries risk of infection (UTI), urinary retention and prostatic trauma inducing hematuria. The purpose of this study was to evaluate whether avoidance of urinary catheter placement during EVAR is an effective practice to reduce cost and morbidity. This was a single-institution, retrospective review of 177 consecutive patients who underwent elective infrarenal EVAR. Ruptured aneurysms and emergent EVAR were excluded. The study end points were postoperative UTI, urinary retention, length of stay, and readmission within 30 days. Univariable analysis was performed for these four outcomes in patients with (N = 92 and without (N = 65) preoperative urinary catheter placement. A more expansive multivariable investigation for risk of urinary retention following EVAR was conducted with binary logistic regression with co-variates including age, sex, femoral cutdown, estimated blood loss (EBL), urinary catheter, congestive heart failure, diabetes, and postoperative urinary retention as co-variates. Patients who had a Urinary catheter placed had an over two fold higher event rate of urinary retention (10.9% vs 4.6%) This urinary retention trend lacked power to reach significance (OR 2.52 (.665-9.55). Placement of urinary catheter also had a strong trend towards increased rate of UTI but lacking power for significance (7.6% vs 3.10%, OR 1.96 (.556-6.57). There was no difference with or without urinary catheter placement regarding 30-day readmission (yes catheter 7.6% vs no catheter 6.2%, P = .725), or length of stay (yes catheter 2.13 days vs no catheter 1.74 days, P = .723). Urinary retention was significantly associated with the development of a UTI with 23% of patients who had retention developing UTI compared with 4.2% of patients without retention developing UTI (adjusted odds ratio = 17.98, P = .019). Increased blood loss (P = .027) was also associated with increased rate of UTI on multivariable analysis. Avoidance of preoperative urinary catheter placement displays a trend towards avoiding urinary retention and UTI. Patients who develop post EVAR urinary retention experience a significantly increased rate of UTI. Selective urinary catheter placement should be used to help reduce urinary-related complications following elective EVAR.

Women Experience Higher Rates of Mortality Following Thoracic Endovascular Aneurysm Repair

ObjectivesThoracic endovascular aortic repair (TEVAR) and complex endovascular thoraco-abdominal aneurysm repair (cEVAR) has been increasingly adopted in the treatment of thoracic and thoracoabdominal aorta aneurysms, offering a less invasive approach for patients with appropriate anatomy. Women usually present with smaller aortic diameter. However, they usually have greater aneurysm growth rates. How sex can affect postoperative and short-term outcomes after TEVAR is not well reported. The aim of this study was to assess outcomes in female versus male patients undergoing TEVAR for treatment of thoracic and thoracoabdominal aneurysms in a Medicare-linked database. MethodsWe retrospectively reviewed patients undergoing TEVAR for thoracic and thoracoabdominal aneurysm repair in the Vascular Quality Initiative (VQI) Vascular Implant Surveillance and Interventional Outcomes Network (VISION) database from 2003 to 2018. Patients were divided into males and females. Patients presented with ruptured aneurysm were excluded from the analysis. Postoperative outcomes included in-hospital stroke, myocardial infarction (MI), spinal cord ischemia, and 30-day mortality. One-year outcomes included mortality, aneurysmal rupture, and reintervention. Postoperative outcomes were assessed using multivariable logistic regression analysis and one-year outcomes were evaluated using Kaplan Meier Survival and Cox regression analyses. ResultsA total of 3,058 males and 1,843 females were available for the analysis. Female patients had smaller median aortic diameter, were more likely to be black, with chronic obstructive pulmonary disease, and chronic kidney disease, and to be symptomatic on presentation. Male patients were more likely to be on preoperative medications such as aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, P2Y12 antagonists, and anticoagulants. After adjusting for potential confounders, female gender was associated with double the risk of in-hospital stroke (OR: 2.3, 95%CI ((1.5-3.7), P<0.001) and 80% increase in 30-day mortality (OR: 1.8, 95%CI (1.3-2.6), P=0.001). At one year, female gender was associated with a higher risk of mortality (HR: 1.2, 95%CI (1.05-1.4), P=0.011). There was a trend towards higher risk of reintervention (HR: 1.2, 95%CI (0.97-1.6), P=0.079). ConclusionsMortality after TEVAR seems to be higher in female patients at 30 days and up to one year of follow-up. Female patients also face a two times higher risk of in-hospital stroke. Future studies with a larger female population should aim to identify and potentially ameliorate the factors associated with these unfavorable outcomes in females.

Impact of Combining Iliac Branch Endoprosthesis and Physician-Modified Fenestrated-Branched Endovascular Repair for Complex Abdominal and Thoracoabdominal Aortic Aneurysms with Concomitant Iliac Artery Aneurysms

ObjectivesTreatment of iliac artery aneurysms (IAA) with the Iliac Branch Endoprosthesis (IBE) during endovascular repair of infrarenal abdominal aortic aneurysm (EVAR) has been well-documented as effective. However, limited data exists evaluating the safety and efficacy of treating complex abdominal (cAAA) and thoracoabdominal aortic aneurysms (TAAA) with associated IAA with combined physician-modified fenestrated branched endovascular aortic repair (PM-FBEVAR) and IBE. Moreover, limited studies exist assessing the impact of adding IBE on the outcomes following PM-FBEVAR. Therefore, we compared the clinical outcomes of patients who underwent PM-FBEVAR with and without IBE for the treatment of cAAA and TAAA. MethodsA single institution retrospective review of consecutive patients who underwent PM-FBEVAR between September 2015 and February 2021 was conducted. Patients with both unilateral and bilateral IBE implantation were included. Infected aneurysms and pseudoaneurysms were excluded. Demographics, technical success, and operative factors were analyzed. Primary outcomes were incidence of pelvic ischemia including buttock and thigh claudication, bowel and spinal cord ischemia, patency of internal and external limbs of IBE, and target vessel instability. Secondary outcomes included technical success, 30-day major adverse events (MAE), 30-day and all-cause mortality, and endoleaks. ResultsAmong 183 patients identified who underwent PM-FBEVAR, 22 patients underwent PM-FBEVAR and IBE with 3 patients treated with bilateral IBEs. There was no pelvic ischemia in the PM-FBEVAR and IBE group. Technical success, fluoroscopy time, and procedure time were comparable between the two groups. Contrast usage was higher in the PM-FBEVAR and IBE group (p=0.01). Thirty-day MAE and mortality were not statistically different between the two groups. At mean follow-up of 23 months, all-cause mortality was similar for both groups (21% vs 27%; p=0.47). Patency of internal iliac artery limb and external iliac artery limb of the IBE were 96% (24 of 25) and 100%, respectively, during mean follow-up of 23 months. The patient with occlusion of internal iliac limb was asymptomatic and received no re-intervention. ConclusionTreatment of cAAA and TAAA associated with IAA using combined PM-FBEVAR and IBE is feasible with high efficacy and safety, and without adverse effect on outcomes. Long-term follow-up is planned to assess durability of repair with PM-FBEVAR and IBE.

Low-Profile Minos TM Stent Graft System for Endovascular Abdominal Aorta Aneurysm Repair—Early and Late Outcomes in Elective and Emergent Situations

BackgroundThe aim of the study was to present the results of a novel abdominal stent graft for patients with Abdominal aortic aneurysm (AAA), through 2 years follow-up. MethodsA single-center retrospective review with prospectively collected data was performed to assess the safety and effectiveness of the Minos Abdominal stent device for treating abdominal aortic aneurysms. We estimated technical success rate, in-hospital and 30-day mortality, and mortality at the end of follow-up as well as complication and reintervention rate in our study cohort. Follow-up imaging assessments consisted of computed tomography angiography (CTA) at 1 and 6 months and yearly thereafter. ResultsA total of 52 patients (92% males; mean age, 74±6 years) were enrolled with Minos Abdominal stent device from July 2020 until September 2023. Thirty one (60%) patients were asymptomatic while 21 (40%) were symptomatic. The technical success of the endovascular aortic repair (EVAR) was 95% (49/52 patients). In 5% (3/52) of the cases, cannulation of the contralateral limb was unsuccessful and was converted to aorto-uni-iliac graft (AIU). Two (4%) aortic related death were recorded during the 30-day period. The major adverse event rate was 3.8%. The overall mean follow-up was 30±6 months; no aorta-related deaths or graft related complications were observed. Sac shrinkage (>5mm) has been observed in 70% of patients. ConclusionsMinos endoprosthesis seems to be safe, effective and durable for treating AAA either in elective or emergent situations.

Massive thoracic aortic dissection in the subacute postpartum period in a patient with Marfan syndrome

Aortic dissection is a life-threatening condition that can result in rupture, massive hemorrhage, and death. Parturients with Marfan syndrome are at increased risk of aortic dissection due to connective tissue dysfunction and physiologic changes secondary to pregnancy. Aortic dissection typically manifests during the intrapartum period, rather than the postpartum course. This article discusses a case of a parturient with Marfan syndrome who suffered a massive thoracic aortic dissection in the subacute postpartum period after an uncomplicated vaginal delivery. Abbreviations: CT - computerized tomography; AD - Aortic dissection; MFS - Marfan syndrome; PPD - postpartum day; TEVAR - thoracic endovascular aortic repair; TTE - transthoracic echocardiogram; VAVD - vacuum assisted vaginal delivery; VD - vaginal delivery Keywords: Marfan Syndrome; Pregnancy; Aortic Dissection; Neuraxial Anesthesia Citation: Dhoon T, Crain NA, Rahimian R, Rajan GR. Massive thoracic aortic dissection in the subacute postpartum period in a patient with Marfan syndrome. Anaesth. pain intensive care 2024;28(5):964−968; DOI: 10.35975/apic.v28i5.2564 Received: May 09, 2024; Reviewed: August 15, 2024; Accepted: August 15, 2024