EVAR Procedures Research Articles

Pivotal Clinical Study to Evaluate the Safety and Effectiveness of the MANTA Vascular Closure Device During Percutaneous EVAR and TEVAR Procedures

Purpose: To evaluate the safety and effectiveness of the MANTA percutaneous vascular closure device in patients undergoing percutaneous endovascular aneurysm repair (PEVAR) or thoracic endovascular aortic repair (TEVAR). Materials and Methods: The SAFE MANTA Study (ClinicalTrials.gov identifier NCT02908880) was a prospective, single-arm, multicenter trial in patients undergoing endovascular interventions using large-bore sheaths (transcatheter aortic valve replacement, PEVAR, or TEVAR) at 20 sites in North America. Patient selection intended to test the MANTA device in populations without morbid obesity, severe calcification, or a severely scarred femoral access area. Of the 263 patients enrolled in the primary analysis cohort, 53 (20.2%) patients (mean age 74.9±8.9 years; 41 men) underwent PEVAR (n=51) or TEVAR (n=2) procedures and form the cohort for this subgroup analysis. Per protocol a single MANTA device was deployed in all PEVAR/TEVAR cases. Results: The mean time to hemostasis in the PEVAR/TEVAR cohort was 35±91 seconds, with a median time of 19 seconds vs 24 seconds in the overall SAFE MANTA population. The MANTA device met the definition for technical success in 52 (98%) of 53 PEVAR/TEVAR cases compared with 97.7% in the overall SAFE MANTA population. One (1.9%) major complication (access-site stenosis) occurred in this subgroup compared to 14 (5.3%) events in the SAFE population. In the PEVAR/TEVAR group, 1 pseudoaneurysm was noted prior to discharge, another at 30-day follow-up, and one at 60 days. One (1.9%) of the 3 minor pseudoaneurysms was treated with ultrasound-guided compression and the other 2 required no treatment. Conclusion: The MANTA device demonstrated a short time to hemostasis and low complication rates compared with published literature results of other percutaneous closure devices. Time to hemostasis and complication rates were comparable between the PEVAR/TEVAR patients and the full SAFE MANTA study cohort. The MANTA device provides reliable closure with a single percutaneous device for PEVAR/TEVAR procedures.

Shall We Think in Using Endoanchors in all EVAR and TEVAR Procedures

Shall We Think in Using Endoanchors in all EVAR and TEVAR Procedures

Respiratory Rehabilitation in Patients with Abdominal Aortic Aneurysm Submitted to OPEN and EVAR Treatment: Predictive Factors of Postoperative Pulmonary Complications and Clinical Implications

Background: In the conventional surgical treatment of aneurysms, the respiratory physiotherapy is one of the cornerstones of patient rehabilitation. The endovascular technique, with less invasiveness, has significantly changed the rehabilitative approach to the operated subject. Objective of the study: to evaluate and compare the effectiveness of the pre and post-operative rehabilitation treatment associated with the conventional OPEN surgery compared to the EVAR procedure and their incidence in preventing postoperative respiratory complications. Design: Longitudinal case control study to compare patients who have open surgery with patients who do not have the laparotomy, as in ENDO technique, to look how frequently the postoperative pneumonia and the risk factor was present in each group to determine the relationship between the risk factor, the type of operation and the pneumonia incidence. Setting Data were collected from patients admitted consecutively at the Tor Vergata Hospital with diagnosis of an abdominal aortic aneurysm. Risk factors, type of intervention, pneumonia incidence in postoperative period was evaluted at 30 days. Population: Three hundred and twenty patient were enrolled. Materials and methods: From 2005 to 2016, 320 patients suffering from an abdominal aortic aneurysm were treated consecutively. One hundred eighty one patients were treated using the open technique (group A) and 139 using the EVAR technique (group B). All patients in OPEN group were submitted to respiratory rehabilitation protocol. Risk factors, type of intervention, anesthesia and results of treatment with complications, observed mortality, mean hospital stay were studied. Pre and postoperative respiratory rehabilitation treatment protocol was performed in all of the patients. The data were analyzed with descriptive statistics and inferential statistics using SPSS 18.0 for Windows. Results: From 2005-2010, the postoperative stay (days) was significant shorter for EVAR compared to open (6.47 vs. 10.48; P 0.001). From 2011-2016, the postoperative stay (days) was significant shorter EVAR compared open (4.07 vs. 11.41; P 0.001). The patients treated from 2011 to 2016 for both OPEN and EVAR groups presented an average age 3 years lower compared to the patients treated in the period from 2005-2011 (75.5 to 72.8 for EVAR and from 71,2 to 68,2). The patients treated from 2011 to 2016 for EVAR group presented an average reduction in post-operative hospitalization of 2.4 days (-37.09%) compared to 2005-2011 period. There was a significant higher incidence of pneumonia in the open group (P=0.001). The reduction of the incidence of pneumonia in group A and B during the two different periods from 2005 to 2010 and from 2011 to 2016 was observed. There wasn’t a significant difference in the incidence of pneumonia in patients treated from 2005 to 2010 (P-value=0.1). In patients treated from 2011 to2016 there was a significant increasing the incidence of pneumonia in OPEN group (P=0.001). Conclusion: Rehabilitation physiotherapy plays a fundamental role in the prevention of postoperative complications of patients undergoing OPEN treatment. Despite of the excellent results obteined in patients undergoing OPEN treatment, the lower rate of complications in EVAR group showed better results of this treatment.

A Detailed Cost Analysis of Complicated and Uncomplicated EVAR and Fevar Procedures in a DRG-System, Conducted at an European Academic Hospital Based Upon a Newly Developed Calculation Model

Introduction - Open aortic repair (OAR) has been more and more replaced by (fenestrated) endovascular aortic repair ((F)EVAR) (1). Outcomes of several cost (efficiency)-analyses have been controversial with studies reporting EVAR to be more cost efficient or equal to open repair; whereas others reported the opposite (2–10). Furthermore, health care costs and value in healthcare have been increasingly discussed, concluding that there is a need for accurate analysis and transparency (11–16).

Development of an Endovascular Training Model for Simulation of Evar Procedures Using 3D Rapid Prototyping for the Production of Exchangeable Patient Specific Anatomic Models

Development of an Endovascular Training Model for Simulation of Evar Procedures Using 3D Rapid Prototyping for the Production of Exchangeable Patient Specific Anatomic Models

Improved technique for sheath supported contralateral limb gate cannulation in endovascular abdominal aortic aneurysm repair.

Background: To present a technique of sheath supported contralateral limb gate (CLG) cannulation of modular bifurcated stent-graft in endovascular abdominal aortic repair. Materials and methods: After totally percutaneous bilateral femoral access, the 9F introducer sheath is exchanged to a 30cm 12 fr introducer sheath over a stiff wire contralateral to the intended main stent-graft insertion side and advanced into the aorta below the lowest renal artery. Parallel to the stiff wire within the sheath an additional standard J-tip guidewire with a 5 fr Pigtail angiographic catheter is advanced to the level of the renal arteries. After main body deployment, the 12 fr introducer sheath and J-tip wire with pigtail catheter are retracted until the CLG opening level, maintaining the stiff "buddy" wire in position to support the 12 fr sheath, maintaining its distal opening close to the contralateral gate opening to achieve easy cannulation. Results: Retrospective analysis of video archive from July 2016 to February 2018 evidenced 55 recorded EVAR cases. All CLG cannulations were obtained with Standard J-tip or Terumo Glidewire wires and with Pig-Tail or Berenstein catheters. Technical success was 100%. Mean fluoroscopy time to accomplish CLG cannulation was 37.6 33 (range 1-105) seconds. The aortic carrefour angulation on coronal axis strongly correlates with cannulation time p=<.001, with longer cannulation time for higher carrefour angulations on coronal axis (Pearson correlation coefficient 0.47). Conclusions: The use of 12 fr sheath with parallel wire introduction technique, appears to be a safe and reliable tool to facilitate CLG cannulation during EVAR procedures.

50. Vascular BehÇet’s disease in a 20-year-old man presenting with an abdominal aortic aneurysm

IntroductionBehçet’s Disease (BD) is a complex, multisystem auto-inflammatory disorder. The most frequent manifestations are oral aphthous ulcers, genital ulcers and uveitis. Vascular involvement is less common but one of the major causes of mortality and morbidity. This case highlights the need to consider BD, especially in young, male, patients with arterial abnormalities and the challenges of treatment.Case descriptionA 20-year-old man with a Moroccan father, presented to A&E with abdominal pain, constipation and night sweats, following recurrent admissions with lower abdominal and back pain. On this occasion he was noted to have a CRP of 160 mg/L and a subsequent CT scan of the abdomen showed a 4 cm pseudo-aneurysm arising from the right lateral infrarenal abdominal aorta which was initially repaired with open surgery and a vein graft. This subsequently leaked and so he had further surgery and an EVAR procedure. On further questioning it was noted that he had had frequent mouth ulcers for seven years and also episodes of epididymo-orchitis and folliculitis and the possibility of BD was considered. He was seen in the Birmingham Behçet’s Centre of Excellence and started azathioprine together with oral prednisolone. Six months later he required embolization of a left renal artery pseudoaneurysm and stent-grafting of the same artery. Given these new changes he was commenced on IV cyclophosphamide.Despite six pulses of cyclophosphamide and high doses of prednisolone he continued to have a raised CRP and so was switched to tocilizumab infusions. His inflammatory markers initially improved, but after about two years he attended for an infusion and complained of worsening abdominal pain. At that point it was noted that his inflammatory markers had been intermittently raised over the preceding few months. There had been a few breaks in treatment due to possible infections and non-attendance. A further CT scan was performed that showed disease progression at the distal site of the graft with small new aneurysms. After an MDT discussion it was decided to switch him to infliximab. He has now been on infliximab for over six months and his inflammatory markers have, reassuringly, remained low. DiscussionArterial involvement in BD is relatively uncommon, presenting variably with stenosis, thrombotic occlusions and aneurysms, as the vasculitic process can affect perivascular and endovascular tissues. Aneurysms are typically seen a number of years after the initial diagnosis and are believed to be due to an obliterative endarteritis with inflammation causing destruction of elastic and muscle cells in the media. The aneurysms tend to be more saccular, and the abdominal aorta is more frequently involved than the thoracic aorta or pulmonary artery. In this case the initial surgical procedure was performed prior to the diagnosis of BD, so it was not possible to give something such as cyclophosphamide prior to surgical intervention which would be advised. The EULAR guidelines recommend cyclophosphamide and corticosteroids as first line in treatment in arterial involvement. However, no further guidance is given regarding subsequent immunosuppression if needed. In this case the decision to start tocilizumab was made based on successful use in other patients with vascular Behçet’s disease.Subsequently infliximab was chosen as it has been used more widely in BD including in patients with vascular BD. Biochemically and symptomatically the patient has been well since infliximab was started, but we are currently awaiting a repeat CT scan. This case has also proved challenging as the patient has struggled with the diagnosis and need for frequent hospital appointments. He has had some help from the psychologist available through the Behçet’s service but has continued to DNA appointments and turn up for infusions at times that suit him. We are hopeful that a longer period of stability will also be beneficial from that point of view. Key learning pointsVascular is less common than other features of BD but can sometimes be a presenting feature and is a major cause of mortality and morbidity. Unlike the international study group (ISG) criteria for Behçet’s disease the international criteria for Behçet’s disease (ICBD) do include vascular lesions. The possibility of BD needs to be considered, especially in patients presenting with potential vascular involvement. For both aortic and peripheral artery aneurysms the 2018 update of the EULAR guidelines recommend medical treatment with cyclophosphamide and corticosteroids before surgical intervention. If there is ongoing arterial disease activity despite cyclophosphamide anti-TNF and IL6 inhibition can be considered and have shown some success. Endovascular surgery is increasingly being preferred to open surgery, although there is a risk of further aneurysm formation, particularly at graft peripheries. Conflicts of interestThe authors have declared no conflicts of interest.

The role of the inferior mesenteric artery in predicting secondary intervention for type II endoleak following endovascular aneurysm repair

ObjectiveEndovascular aneurysm repair (EVAR) is associated with a greater risk of graft-related complications and need for secondary interventions compared with open repair. Type II endoleak (EL-2) is the most common complication. We examined the hypothesis that a functionally occluded inferior mesenteric artery (IMA) before EVAR was associated with fewer secondary interventions for EL-2. MethodsAll nonruptured abdominal aortic aneurysms (AAA) treated by EVAR using U.S. Food and Drug Administration-approved endografts from January 2005 to December 2017 were retrospectively reviewed, including computed tomography angiograms. Preoperative patency of the IMA and any secondary interventions performed after the index EVAR procedure were recorded. A functionally occluded IMA was defined as one that was (1) chronically occluded or severely stenosed on preoperative imaging or (2) coil embolized before EVAR. Secondary interventions for persistent EL-2 were indicated when AAA sac diameter increased by more than 5 mm. ResultsThe study cohort comprised 490 patients (84 women) with a mean age of 74.8 ± 8.2 years. The mean preoperative AAA diameter was 5.6 ± 0.9 cm. One hundred twenty-nine patients (26.3%) died during follow-up. The mean follow-up of survivors was 38 months. Types (prevalence) of endoleak were I (2.4%), II (18.9%), III (0.7%), IV (0.5%), and V (0.2%). Patients with a functionally occluded IMA underwent significantly fewer secondary interventions for EL-2 compared with patients with a patent IMA (2.6% vs 7.1%; P = .020). All secondary interventions in the functionally occluded IMA group involved the lumbar arteries (LA). When the IMA was patent, secondary interventions were equally distributed between the LA and IMA. Logistic regression confirmed that a functionally patent IMA was associated with a greater number of secondary interventions for EL-2 (odds ratio, 3.0; 95% confidence interval, 1.2-7.5; P = .025). ConclusionsPatients with a functionally occluded IMA required significantly fewer secondary interventions for EL-2 after EVAR. In addition, the type of vessels intervened on were primarily LA. Among patients with a patent IMA, preoperative coil embolization may decrease secondary interventions and improve the long-term durability of EVAR.

Unplanned 30-day readmissions after endovascular aneurysm repair: An analysis using the Nationwide Readmissions Database

BackgroundEndovascular aneurysm repair (EVAR) is the preferred method for addressing abdominal aortic aneurysms (AAAs), with proven reduction in perioperative morbidity and mortality. There are, however limited data examining the readmissions after EVAR that are associated with increased patient morbidity and cost. As EVAR use continues its dominance in the management of AAAs, it becomes imperative to identify and mitigate risk factors associated with unplanned hospital readmissions. MethodsThe Nationwide Readmissions Database (NRD) was queried for all 30-day readmissions after an index EVAR procedure from 2012 to 2014. Preoperative patient demographics, hospital characteristics, readmission diagnosis, and costs were compared between those who were and were not readmitted within 30 days of the index operation. Multivariable logistic regression was used to identify potential risk factors associated with unplanned readmissions within 30 days. ResultsWe identified 120,646 patients who underwent an EVAR from 2012 to 2014 in the United States. The overall unplanned readmission rate during this period was 11.6% (n = 14,073) within 30 days of the index EVAR procedure. The readmission rate was the highest in 2012, with a rate of 12.3% (P = .02). Multivariate regression analysis showed that EVAR readmissions were significantly higher in patients who were of younger age (18 to 49 years) compared with other age groups (odds ratio [OR], 1.9-2.17; P < .001), female sex (OR, 1.367; P < .001), had Medicare (OR, 1.39) or Medicaid (OR, 1.25) insurance, or a combination of these. Underlying patient comorbidities significantly associated with readmissions included congestive heart failure (OR, 2.4), peripheral vascular disease (OR, 1.1), chronic pulmonary disease (OR, 1.2), cancer with no metastasis (OR, 1.5), metastatic cancer (OR, 2.2), renal failure (OR, 1.8), and diabetes (OR, 1.5). ConclusionsThe trend in 30-day readmission rates after EVAR has decreased slightly since 2012, but overall rates are at 11.6%, which is not insubstantial. Patient factors strongly associated with hospital readmission were younger age and patient comorbidities, including congestive heart failure, concurrent cancer diagnosis, renal failure, and diabetes.

ИСПОЛЬЗОВАНИЕ ТЕХНИКИ «CHIMNEY» В УСТРАНЕНИИ ЭНДОЛИКА IA ТИПА ПОСЛЕ ЭНДОПРОТЕЗИРОВАНИЯ БРЮШНОЙ АОРТЫ ПРИ ЕЁ АНЕВРИЗМЕ

A 73 year old man who underwent an elective EVAR procedure in 2014 for an infrarenal AAA presented two years later with a type IA endoleak. The CTA showed a distal migration of the proximal part of the stent graft resulting in a type IA endoleak. In order to treat this new diagnosed endoleak an endovascular repair using chimney technique (with a snorkel-stent graft in the renal artery-bilaterally) with proximal extension of sealing zone with an endovascular aortic cuff has been undergone with implantation of a stent graft in the right renal artery as a periscope and a chimney in the left renal artery. Subsequently, an Endurant II Aortic Cuff was implanted. The whole procedure was performed using CO2 instead of iodinated contrast medium. In the 5 month follow-up with abdominal ultrasonography no endoleak could be identified with stabilization of aneurysmal sac diameter. The use of chimney technique adds an additional tool to the armamentarium of endovascular surgeon to deal with the complex type IA endoleaks Keywords: Abdominal aneurysm , CO2 angiography , chimney-graft technique, type IA endoleak, periscope technique.

VD12 HYBRID TOTAL ENDOVASCULAR AORTIC REPAIR WITH CHIMNEY TECHNIQUE

Abstract Total endovascular techniques, such as fenestrated and branched techniques, provide a less invasive and safer solution to aortic arch diseases in high risk patients. We report the case of a 69-year old Marfan's syndrome female with a post-dissection aortic arch aneurysm. Previously, the patient underwent Bentall procedure and an endovascular stenting for right renal artery aneurysm. Computed tomography angiography revealed a dissecting aneurysm of aortic arch and supra-aortic branches perfused by the true lumen. Hybrid repair of the dissection was considered primarily; however, the patient refused sternotomy. We fixed the aneurysm using TEVAR and used the chimney technique to reconstruct the supra-aortic vessels. Final control angiography confirmed complete exclusion of the aortic arch injury and the patency of the supra-aortic branches. We repaired also the abdominal aortic aneurysm performing an EVAR procedure. The patient is doing well after 3-months follow-up. Endovascular procedures can be used successfully for dissecting aortic aneurysm.

Navigation and visualisation with HoloLens in endovascular aortic repair.

IntroductionEndovascular aortic repair (EVAR) is a minimal-invasive technique that prevents life-threatening rupture in patients with aortic pathologies by implantation of an endoluminal stent graft. During the endovascular procedure, device navigation is currently performed by fluoroscopy in combination with digital subtraction angiography. This study presents the current iterative process of biomedical engineering within the disruptive interdisciplinary project Nav EVAR, which includes advanced navigation, image techniques and augmented reality with the aim of reducing side effects (namely radiation exposure and contrast agent administration) and optimising visualisation during EVAR procedures. This article describes the current prototype developed in this project and the experiments conducted to evaluate it.MethodsThe current approach of the Nav EVAR project is guiding EVAR interventions in real-time with an electromagnetic tracking system after attaching a sensor on the catheter tip and displaying this information on Microsoft HoloLens glasses. This augmented reality technology enables the visualisation of virtual objects superimposed on the real environment. These virtual objects include three-dimensional (3D) objects (namely 3D models of the skin and vascular structures) and two-dimensional (2D) objects [namely orthogonal views of computed tomography (CT) angiograms, 2D images of 3D vascular models, and 2D images of a new virtual angioscopy whose appearance of the vessel wall follows that shown in ex vivo and in vivo angioscopies]. Specific external markers were designed to be used as landmarks in the registration process to map the tracking data and radiological data into a common space. In addition, the use of real-time 3D ultrasound (US) is also under evaluation in the Nav EVAR project for guiding endovascular tools and updating navigation with intraoperative imaging. US volumes are streamed from the US system to HoloLens and visualised at a certain distance from the probe by tracking augmented reality markers. A human model torso that includes a 3D printed patient-specific aortic model was built to provide a realistic test environment for evaluation of technical components in the Nav EVAR project. The solutions presented in this study were tested by using an US training model and the aortic-aneurysm phantom.ResultsDuring the navigation of the catheter tip in the US training model, the 3D models of the phantom surface and vessels were visualised on HoloLens. In addition, a virtual angioscopy was also built from a CT scan of the aortic-aneurysm phantom. The external markers designed for this study were visible in the CT scan and the electromagnetically tracked pointer fitted in each marker hole. US volumes of the US training model were sent from the US system to HoloLens in order to display them, showing a latency of 259±86 ms (mean±standard deviation).ConclusionThe Nav EVAR project tackles the problem of radiation exposure and contrast agent administration during EVAR interventions by using a multidisciplinary approach to guide the endovascular tools. Its current state presents several limitations such as the rigid alignment between preoperative data and the simulated patient. Nevertheless, the techniques shown in this study in combination with fibre Bragg gratings and optical coherence tomography are a promising approach to overcome the problems of EVAR interventions.

A Cost Calculation of EVAR and FEVAR Procedures at an European Academic Hospital

The aim was to calculate the costs of EVAR and FEVAR procedures in a European academic hospital by cost retrieval based on a subcohort with known detailed costs through application of the individually detailed calculated costs to the total study population and to correlate these with corresponding reimbursements. A cost analysis was performed on 25 FEVAR and 100 EVAR cases based on the detailed cost analysis of a group of patients treated in 2012 and 2013 by applying the costs based on costs per time unit within 4 subgroups: (1) uncomplicated EVAR, (2) complicated EVAR, (3) uncomplicated FEVAR, and (4) complicated FEVAR. Thirty cases (19 EVAR and 11 FEVAR) treated in 2012 and 2013 were used to determine the individual detailed costs for the entire study group consisting of 100 EVAR and 25 FEVAR cases. There were 14 repeat operations within the 100 EVAR cases and 3 repeat operations within the 25 FEVAR cases. A total of 14 EVAR-treated patients were readmitted, as was one FEVAR patient. The costs of the endografts were the largest contributor to the overall costs, followed by the costs of the surgery itself and the stay in the ward. The costs of an uncomplicated EVAR procedure summed up at €12,090; a complicated EVAR procedure costs €13,956. An uncomplicated FEVAR procedure costs €34,807, and a complicated FEVAR procedure costs €36,695. The difference between median reimbursements received for the uncomplicated EVAR and FEVAR procedures was significant with €13,374 for uncomplicated FEVAR and €11,486 for complicated FEVAR in favor of the FEVAR group (P<0.05). No financial loss was calculated in any of the subgroups. The costs of the endografts were the largest contributor to the overall costs, followed by the costs of the surgery itself and the stay in the ward.

Fusion Imaging for EVAR with Mobile C-arm

Fusion imaging is a technique that facilitates endovascular navigation but is only available in hybrid rooms. The goal of this study was to evaluate the feasibility of fusion imaging with a mobile C-arm in a conventional operating room through the use of an angionavigation station. From May 2016 to June 2017, the study included all patients who underwent an aortic stent graft procedure in a conventional operating room with a mobile flat-panel detector (Cios Alpha, Siemens) connected to an angionavigation station (EndoNaut, Therenva). The intention was to perform preoperative 3D computerized tomography/perioperative 2D fluoroscopy fusion imaging using an automatic registration process. Registration was considered successful when the software was able to correctly overlay preoperative 3D vascular structures onto the fluoroscopy image. For EVAR, contrast dose, operation time, and fluoroscopy time (FT) were compared with those of a control group drawn from the department's database who underwent a procedure with a C-arm image intensifier. The study included 54 patients, and the procedures performed were 49 EVAR, 2 TEVAR, 2 IBD, and 1 FEVAR. Of the 178 registrations that were initialized, it was possible to use the fusion imaging in 170 cases, that is, a 95.5% success rate. In the EVAR comparison, there were no difference with the control group (n=103) for FT (21.9±12 vs. 19.5±13min; P=0.27), but less contrast agent was used in the group undergoing a procedure with the angionavigation station (42.3±22mL vs. 81.2±48mL; P<0.001), and operation time was shorter (114±44 vs. 140.8±38min; P<0.0001). Fusion imaging is feasible with a mobile C-arm in a conventional operating room and thus represents an alternative to hybrid rooms. Its clinical benefits should be evaluated in a randomized series, but our study already suggests that EVAR procedures might be facilitated with an angionavigation system.

Comparison of access type on perioperative outcomes after endovascular aortic aneurysm repair

ObjectiveEndovascular aneurysm repair (EVAR) can be performed through percutaneous or surgical access. Our goal was to assess the difference in perioperative outcomes based on access type in a real-world setting. MethodsThe Vascular Quality Initiative (VQI) database was queried for EVAR. Univariable analysis and multivariable analysis were used to determine the independent effect of access type. ResultsThere were 8340 (64%) and 4747 (36%) EVAR procedures performed through percutaneous and surgical access (3395 [72%] transverse and 1352 [28%] vertical incisions). In 347 cases (4%), percutaneous access failed. Percutaneous access was performed more in patients who were younger and male, had higher body mass index, were nonsmokers, and had commercial insurance. Multivariable analysis showed that surgical transverse compared with percutaneous access was associated with more cardiac complications (odds ratio, 1.53; 95% confidence interval [CI], 1.14-2.05; P = .005), prolonged operative time (means ratio [MR], 1.25; 95% CI, 1.23-1.27; P < .001), larger estimated blood loss (EBL; MR, 1.51; 95% CI, 1.45-1.57; P < .001), and length of stay (LOS; MR, 1.28; 95% CI, 1.23-1.32; P < .001). Open surgical access through vertical incisions compared with percutaneous access was associated with prolonged operative time (MR, 1.34; 95% CI, 1.31-1.37; P < .001), larger EBL (MR, 1.67; 95% CI, 1.58-1.77; P < .001), and LOS (MR, 1.49; 95% CI, 1.42-1.57; P < .001). Open access through a vertical incision compared with a transverse incision was associated with prolonged operative time (MR, 1.07; 95% CI, 1.04-1.1; P < .001), larger EBL (MR, 1.1; 95% CI, 1.04-1.18; P = .001), and LOS (MR, 1.17; 95% CI, 1.1-1.23; P < .001). Failed percutaneous access was seen more with previous bypass, ruptured aneurysm repair, general anesthesia, female sex, obesity, coronary artery disease, and preoperative aspirin use. Failed percutaneous access was associated with increased cardiac complications (odds ratio, 2.48; 95% CI, 1.38-4.6; P = .003), prolonged operative time (MR, 1.64; 95% CI, 1.56-1.72; P < .001), larger EBL (MR, 3.27; 95% CI, 2.95-3.62; P < .001), and longer postoperative LOS (MR, 1.47; 95% CI, 1.35-1.6; P < .001). There was no independent effect of access type on respiratory and lower extremity ischemic complications or mortality. ConclusionsThe rate of percutaneous access in this contemporary series is higher than historically reported. Percutaneous access is associated with decreased operative time, EBL, and LOS and should be considered when possible. For open surgical access, transverse incisions are associated with lower operative time, EBL, and LOS. Failed percutaneous access is associated with higher cardiac complications as well as with operative time, EBL, and LOS. Extra caution should be used with patients at high risk for failed percutaneous access. Further prospective investigation is needed incorporating details about the quality of the access vessel to determine the interactions of these risk factors.

Commentary: The Significance of a Fast-Track EVAR Procedure: It’s Not the Years in Your Life That Count, It’s the Life in Your Years

Commentary: The Significance of a Fast-Track EVAR Procedure: It’s Not the Years in Your Life That Count, It’s the Life in Your Years

Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over 9 Years

Background Case mix and outcomes of complex surgical procedures vary over time and between regions. This study analyses peri-operative mortality after intact abdominal aortic aneurysm (AAA) repair in 11 countries over 9 years. Methods Data on primary AAA repair from vascular surgery registries in 11 countries for the years 2005–2009 and 2010–2013 were analysed. Multivariate adjusted logistic regression analyses were carried out to adjust for variations in case mix. Results A total of 83,253 patients were included. Over the two periods, the proportion of patients ≥80 years old increased (18.5% vs. 23.1%; p p p p p p p = .008). The peri-operative risk was greater for octogenarians (overall, 3.6% vs. 2.1%, p p p p p p p Conclusions In this large international cohort, total peri-operative mortality continues to fall for the treatment of intact AAAs. The number of EVAR procedures now exceeds open procedures. Mortality after EVAR has decreased, but mortality for open operations has increased. The peri-operative mortality for small AAA treatment, particularly open surgical repair, is still considerable and should be weighed against the risk of rupture.

Retrospective Evaluation of Percutaneous Access for TEVAR and EVAR: Time to Make it the Standard Approach?

Introduction To evaluate the safety of percutaneous endovascular aortic repair and the relationship of access site characteristics to complications Materials and Methods All patients undergoing percutaneous TEVAR, EVAR and FEVAR procedures from January 2010 to May 2016 were retrospectively analysed for incidence of complications and their relationship to various access site characteristics like access artery size, degree of vessel calcification, skin to artery distance and sheath to artery ratio. Hemostasis occurring within 15 min after suture closure with or without manual compression was defined as primary hemostasis. Results 92 patients with 142 femoral access sites were included in the study. Median follow-up was 28.13 months (range 2.5 - 76.7 months, Mean 32.39, SD - 21.66 months). Introducer system size ranged from 12F to 25F. Primary haemostasis was achieved in 97.1 % (138/142) of the total femoral access sites. Four access sites (2.8 %) had to be closed surgically; in all 4 cases the introducer systems was ≥ 18F. Two of these access sites had been operated upon previously. Late complications including inguinal hematoma (n = 7), wound infection (n = 1), scrotal hematoma (n = 1), pseudoaneurysm (n = 4) and late bleeding (n = 4) occurred in 17 access sites (11.9 %), of which 13 were managed conservatively. On account of the low complication rate, no correlation between the evaluated variables and observed complications could be established. Conclusion Percutaneous endovascular aortic repair is feasible and safe irrespective of the size of the introducer sheath and the nature of aorto-iliac pathology. The technical success rate is high and the incidence of complications is low. Early complications are most often associated with sheath sizes ≥ 18 F. The majority of the late complications can be treated conservatively. Key points: · Percutaneous endovascular aortic repair is feasible and safe.. · Technical success rate is high and complication rate is low.. · Vascular closure device failure in the occasional patient may necessitate surgical intervention.. Citation Format · Thomas RP, Kowald T, Schmuck B et al. Retrospective Evaluation of Percutaneous Access for TEVAR and EVAR: Time to Make it the Standard Approach?. Fortschr Röntgenstr 2017; 189: 347 - 355.

Percutaneous endovascular aneurysm repair in morbidly obese patients

ObjectiveEndovascular aneurysm repair (EVAR) with percutaneous femoral access (PEVAR) has several potential advantages. Morbidly obese (MO) patients present unique anatomical challenges and have not been specifically studied. This study examines the trends in the use of PEVAR and its surgical outcomes compared with open femoral cutdown (CEVAR) in MO patients. MethodsThe American College of Surgeons National Surgical Quality Improvement Program files for the years 2005 to 2013 were reviewed. The study included all MO patients (body mass index [BMI] ≥40 kg/m2) undergoing EVAR. Patients were categorized as having CEVAR if they had any one of 11 selected Current Procedural Terminology (American Medical Association, Chicago, Ill) codes describing an open femoral procedure. The PEVAR group included any remaining patients who had only codes for EVAR and endovascular procedures. Linear correlation was used to evaluate temporal trends in the use of PEVAR among MO patients. Baseline comorbidities and surgical outcomes were compared between the PEVAR and CEVAR groups using χ2 tests or t-tests. ResultsThere were 833 MO patients (470 CEVAR and 363 PEVAR) constituting 3.0% of all patients undergoing EVAR. The use of PEVAR in MO patients significantly increased from 27.3% of total EVARs in the years 2005 to 2006 to 48.6% in 2013 (P = .039). The two groups had similar baseline characteristics, including age, BMI, comorbidities, and emergency procedures, except for history of severe chronic obstructive pulmonary disease (29.6% CEVAR vs 22.6% PEVAR; P = .024). PEVAR patients had shorter duration of anesthesia (244 vs 260 minutes; P = .048) and shorter total operation time (158 vs 174 minutes; P = .002). PEVAR patients had significantly decreased wound complications (5.5% vs 9.4%; P = .039). There was a trend towards PEVAR patients being more likely to be discharged home than to a facility (93.6% vs 87.8%; P = .060). There was no difference in any other complication or mortality. A subgroup analysis of 109 superobese patients with BMI ≥50 kg/mg2 (59 CEVAR and 50 PEVAR) demonstrated no significant differences in outcomes between groups. ConclusionsPEVAR is increasingly used in MO patients and decreases operating time and rates of wound infection compared with CEVAR. The advantages of PEVAR seem to be lost in the superobese patients.

Commentary on “Pre-operative Simulation of the Appropriate C-Arm Position Using Computed Tomography Post-Processing Software Reduces Radiation and Contrast Medium Exposure During EVAR Procedures”

Commentary on “Pre-operative Simulation of the Appropriate C-Arm Position Using Computed Tomography Post-Processing Software Reduces Radiation and Contrast Medium Exposure During EVAR Procedures”