Endovascular Aneurysm Repair Research Articles

Percutaneous Closure Device Controlled INCRAFT Stentgraft Implantation Registry (PUCCINI)

BackgroundPercutaneous endovascular repair (PEVAR) of infra-renal abdominal aortic aneurysms (AAA) is increasingly being performed due to the development of low profile endografts and the use of percutaneous closure devices. The feasibility and safety of the use of the INCRAFT AAA Stentgraft System and the ProGlide vascular closure system was assessed.MethodsThe PUCCINI trial prospectively enrolled patients undergoing elective repair of infrarenal AAA at 3 centres in the Netherlands and 3 centres in Belgium. Patients underwent PEVAR with endograft implantation followed by closure using the ProGlide closure device. Procedural success rates, complications and 30-day follow-up outcomes were collected.ResultsA total of 93 patients, 87% male, were enrolled. The mean aneurysmal diameter was 53.9 ± 10.2 mm. Successful ProGlide placement was achieved in 97.2% in the right and 89.8% in the left groin. Successful closure was achieved in 92.4% of right and 90% of left groins. One patient required surgical access and two surgical closure. Average blood loss was 155.6 ± 175.5ml. Blood transfusion was not required. Average length of hospital stay was 2.1 ± 1.3 days. Post-implantation endoleaks were present in 37 (40.2%) patients (type 1: 12, type 2: 25). At 30-days there was no aneurysmal growth and no deaths. Follow-up imaging showed endoleaks in 39 (41.9%) patients. (type 1:8, type 2:29, type 3:2).ConclusionThe results from the PUCCINI trial demonstrate that the use of a low profile endoprosthesis for treatment of infrarenal AAA with percutaneous closure has a high rate of technical success and low rates of periprocedural complication.

Open Conversion After Branched Endovascular Aortic Repair With a Novel Hybrid Graft.

This technical note introduces the first open surgical conversion after a failed branched endovascular repair of a thoracoabdominal aortic aneurysm, using the new hybrid Thoracoflo device. This innovative technique reduces reno-visceral ischemia time and can be performed through a xipho-pubic laparotomy without the need for extracorporeal circulation. It offers a safe and effective solution for complex thoracoabdominal aortic diseases, and can also serve as a bailout option following endovascular failure.

Radiation Exposure from Preemptive Coil Embolization vs. Secondary Interventions for Endoleak-Induced Aneurysm Sac Growth following Endovascular Abdominal Aortic Aneurysm Repair.

Preemptive embolization of the inferior mesenteric artery (IMA) and lumbar arteries (LA) has been shown to reduce aneurysm sac growth and secondary interventions following endovascular aneurysm repair (EVAR). It is unclear if this strategy will increase radiation exposure compared to secondary interventions performed for endoleak-induced sac growth. We examined the cumulative procedural radiation exposure associated with preemptive embolization of aneurysm sac branches and compared it to that of secondary interventions. A retrospective analysis was performed on patients who underwent EVAR for non-ruptured, infrarenal abdominal aortic aneurysms (AAA) from January 2012 to December 2022, followed-up until February 2024. Procedural radiation data was collected using fluoroscopy time (mins), dose area product (DAP, μGym2), and radiation dose (mGy). Cumulative radiation exposure included preemptive embolization, EVAR, and any endovascular secondary interventions for sac growth. There were 112 patients (90 male, mean age 72.4±8.3 yrs., mean AAA diameter 58.4±12.3 mm) with available radiation data. Preemptive embolization was associated with significantly fewer secondary interventions (8/55 [14.5%] preemptive embolization only vs. 20/57 [35%] no preemptive embolization, needed secondary intervention, p=0.012). Patients were grouped as follows: Group 0 (G0) no preemptive embolization or secondary intervention (n=37), Group 1 (G1) preemptive embolization only (n=47), Group 2 (G2) secondary intervention only (n=20), Group 3 (G3) both preemptive embolization and secondary intervention (n=8). Fluoroscopy time, total DAP, and radiation dose from EVAR did not differ significantly among the four groups. Radiation exposure was significantly higher in those with secondary intervention only (G2: DAP 110,567 μGym2 ±132,296) compared to those who were preemptively embolized and still needed a secondary intervention (G3: DAP 71,566 μGym2 ±49,592, p=0.0016). This is because patients with secondary interventions only required more sessions of endovascular procedures compared to those who received preemptive embolization and still required secondary interventions (G2: 2.2 vs G3: 1.23 sessions, p<0.001). Total radiation exposure was significantly different across groups, with the highest in patients who received secondary interventions only (Group 2). Preemptive embolization of aneurysm sac branches was associated with less secondary interventions for sac growth post-EVAR. Cumulative radiation exposure in patients who received preemptive embolization was significantly less compared to that in patients who underwent secondary interventions for endoleak-induced sac growth. Preemptive embolization may mitigate secondary interventions and reduce overall radiation exposure in patients with AAA being treated with EVAR.

The Retrograde-Access Gutter Snare (RAGS) Technique: A Bailout Maneuver to Maintain Patency of the Left Subclavian Artery in Fenestrated TEVAR.

The purpose of this study is to describe a new bailout maneuver for use during fenestrated thoracic endovascular aneurysm repair (fTEVAR) in the event of wire wrap or wire entanglement with the proximal graft fabric. A 68-year-old-man with hypertension and chronic atrial fibrillation underwent elective thoracic endovascular aneurysm repair (TEVAR) with a left subclavian fenestration to treat a residual arch and thoracic aortic aneurysm after previous type A dissection repair. The procedure was challenging due to malrotation of the main body graft, as well as wire entanglement of the precannulated through-and-through wire on the leading edge of the main body fabric. A novel bailout maneuver is described. Through-and-through access was maintained, and a long 8F sheath was delivered through the fenestration from femoral access, and an 8.5F steerable sheath was delivered through upper extremity access. This allowed coaxial snaring of a new through-and-through wire via the gutter between the stent-graft and native aorta in the seal zone, which both reoriented the fenestration, and permitted placement of a bridging stent to the left subclavian artery. The retrograde-access gutter snare (RAGS) technique described above provides a streamlined approach to achieve technical success in challenging fenestrated thoracic endovascular aneurysm repair (fTEVAR) cases. This technical note describes the retrograde-access gutter snare (RAGS) technique that can provide a successful bailout maneuver for fenestrated TEVAR (fTEVAR) devices. The RAGS technique offers an approach to be used with precannulated custom-made or physician-modified fTEVAR devices in which wire wrap or wire entanglement precludes access through the fenestration after deployment of the main body device. Instead of traditional attempts at de novo cannulation of the fenestration from upper extremity or femoral access, the maneuver offers an approach to maintaining through-and-through access to facilitate snaring a new wire proximal to the leading edge of the main body fabric, which can then be used to deliver a covered stent into the fenestration from either the upper extremity or femoral access. This technique offers an added benefit of potentially realigning malrotated fenestrations via tensioning of the new through-and-through wire.

Thoracic Endovascular Aortic Repair for Aortic Arch Penetrating Atherosclerotic Ulcer Using Castor Single-Branched Stent-Graft With Zone 2 Landing.

This study evaluated the feasibility and safety of thoracic endovascular aortic repair (TEVAR) for aortic arch penetrating atherosclerotic ulcer (PAU) using Castor single-branched stent-graft with zone 2 landing. Between May 2020 and April 2022, a total of 25 aortic arch PAU patients were treated by TEVAR with Castor single-branched stent-graft. Outcomes included technical success, perioperative and follow-up morbidity and mortality, and patency of left subclavian artery (LSA). All patients had aortic arch PAU with intramural hematoma (IMH). The proximal landing zone for all patients was in zone 2, which was between the distal edge of the left common carotid artery and proximal edge of LSA, in all cases. Technical success was achieved in all cases. During hospitalization after the operation, 1 patient died of gastrointestinal bleeding, and 2 patients (8.0%) had ischemic stroke. At a median follow-up of 29 months (interquartile range [IQR], 24-30 months), 2 (8.0%) patients died, including 1 ischemic stroke and 1 hemorrhagic stroke. One patient (4.0%) had reintervention owing to retrograde type A aortic dissection (RTAD) 2 months after the operation, and was successfully treated with aortic root remodeling, ascending aorta and total aortic arch replacement and frozen elephant trunk procedure. No endoleak or LSA occlusion occurred. The maximal diameter of aorta at proximal (30.2±2.4 mm vs 31.2±3.0 mm; p>0.05) and distal (25.7±2.8 mm vs 24.5±2.3 mm; p>0.05) landing zone showed no significant difference before and after the operation. The TEVAR for aortic arch PAU using Castor single-branched stent-graft is a safe and efficient option with zone 2 landing. For patients with diagnosis of PAU with IMH, TEVAR with Castor single-branched stent-graft presents low mid-term mortality and morbidity rate, which should be considered as an optimal option when proximal landing zone is insufficient and revascularization of left subclavian artery (LSA) is needed. With Castor single-branched stent-graft, LSA could be revascularized easily and accurately.

The Role of Dynamic Computed Tomography Angiography in Endoleak Detection and Classification After Endovascular Aneurysm Repair: A Comprehensive Review

Backgroud: The use of dynamic computed tomography angiography (dCTA) for the detection of endoleaks in patients who underwent endovascular repair of abdominal aortic aneurysms is gaining interest. This study aims to provide an overview of the current applications of dCTA technologies in vascular surgery. Methods: We performed a comprehensive review by searching in the PubMed database and Cochrane Library (last search: 1 November 2024). We included studies considering endoleak investigation after endovascular aneurysm repair (EVAR). We included papers that reported the outcome of applications of dCTA, excluding case reports or very limited case series (≤4). Finally, 14 studies regarding 377 computed tomography angiographies (CTA) were included and evaluated. Results: Persistent perfusion of the aneurysm sac is the most common complication after EVAR. Imaging-based surveillance post-EVAR is essential with the aim of early detection, characterization, and localization of endoleaks to guide therapeutic intervention or follow-up. dCTA detected 36 type I endoleaks versus 16 identified with standard CTA and 138 versus 95 type II endoleaks. Conclusions: The emergence of dCTA offers a promising solution through enhanced temporal resolution, allowing the visualization of real-time flow dynamics within the aneurysmal sac essential to establishing endoleak treatment or post-EVAR follow-up.

Endovascular Aortic Aneurysm Repair for Abdominal Aortic Aneurysm With Type V Horseshoe Kidney.

Abdominal aortic aneurysm (AAA) with concomitant Horseshoe kidney (HSK) is rare. When open surgery is not feasible, preserving the renal isthmus artery (RIA) during endovascular treatment presents a challenge. A 70-year-old male presented with a 57.8 mm × 54.3 mm AAA and type V HSK perfused by a 4.4 mm RIA from the inferior mesenteric artery and a 4.6 mm RIA from the aortic bifurcation. This case report describes an endovascular aortic aneurysm repair (EVAR) performed on an AAA coexisting with a type V HSK. One-year follow-up: the AAA had regressed, and the HSK remained perfused without any endoleak or increase in serum creatinine levels. The utilization of EVAR offers a feasible option for AAA combined with type V HSK, particularly in cases of high surgical risk. In Abdominal aortic aneurysm (AAA) with type V horseshoe kidney (HSK), preserving renal isthmus arteries (RIAs) is critical when they provide a substantial portion of the HSK blood supply.When open surgery is not feasible, preserving the RIA during endovascular treatment presents a challenge.The use of EVAR, incorporating a periscope stent and embolization, provides a viable treatment option for patients with AAA and type V HSK, especially in high surgical risk cases.

Endovascular repair of an aortic aneurysm incorporating eight branches

AbstractThoracoabdominal aneurysms with extent I and II usually represent a challenge for endovascular aortic repair, given the absent proximal landing zone for a standard thoracic endovascular aortic repair. We report a successful endovascular treatment of such an aneurysm with a staged complex repair incorporating a total of eight branches, without the need of a surgical bypass.

Roy K. Greenberg and His Work on Endovascular Aortic Aneurysm Repair.

Roy K. Greenberg and His Work on Endovascular Aortic Aneurysm Repair.

A 10-year Retrospective Comparison of Endovascular and Open Aneurysm Repair for Infective Native Abdominal Aortic Aneurysm

BackgroundThis study compared outcomes of endovascular aneurysm repair (EVAR) and open aneurysm repair (OAR) in patients with infective native abdominal aortic aneurysms (INAAA), evaluating perioperative and in-hospital mortality, antibiotic treatment duration, complications, overall survival rates, and reintervention-free times at 10 years. MethodsA retrospective cohort study of 125 INAAA patients (80 EVAR, 45 OAR) diagnosed between January 2004 and December 2019 was conducted. Patients were categorized as fit or unfit for open surgery based on cardiac, respiratory, and renal status, following the guidelines established in the EVAR-1 and EVAR-2 trials. Primary outcomes included 30-day and in-hospital mortality. Secondary outcomes encompassed early and late complications requiring reintervention, antibiotic treatment duration, 10-year overall survival, 10-year reintervention-free survival, and factors influencing 30-day mortality. Statistical analysis used chi-square, t-tests, and Mann-Whitney U tests. Logistic regression assessed mortality. Kaplan-Meier estimation evaluated survival. Analyses used SPSS version 18.0 (p < 0.05 considered significant) ResultsMales predominated in both OAR (37/45, 82.2%) and EVAR (62/80, 77.5%) groups (P = 0.693). Mean age was 64.8 ± 9.8 years for OAR and 69.0 ± 12.6 years for EVAR (P = 0.063). The abdominal aorta was the most common aneurysm location, accounting for 91/125 (72.8%) cases. Salmonella spp. accounted for 19/45 (42.2%) of positive culture cases, and 34/125 (27.2%) patients had ruptured aneurysms. The EVAR group had a higher proportion of unfit patients (41/80, 51.2%) compared to OAR (10/45,22.2%; P=0.003). 30-day mortality rates were 6/80 (7.5%) for EVAR and 2/45 (4.4%) for OAR; OR = 1.75 (95% CI: 0.34 - 9.06), P = 0.508, while in-hospital mortality rates were 7/80 (8.8%) and 5/45 (11.1%); OR = 0.77 (95% CI: 0.23 - 2.58), P = 0.668. No significant differences were found in antibiotic treatment duration (median 11 vs 6 months, P=0.594), 10-year overall survival rates (62.8% vs 64.8%, P=0.90), or reintervention-free time (83.8% vs 82.2%, P=0.922), and aneurysm-related death (84.7% vs 92.9%, P=0.159), Unfit patient status was an independent predictor of 30-day mortality (adjusted OR, 10.654; 95% CI, 1.041-109.030; P=0.046). ConclusionsOur study demonstrates that EVAR and OAR provide comparable outcomes in INAAA management, despite EVAR being performed more frequently in unfit patients. The similar early mortality rates, antibiotic treatment durations, and long-term survival between the two approaches support EVAR as a viable alternative to OAR. Importantly, our finding that unfit patient status independently predicts perioperative mortality emphasizes the critical role of patient selection in treatment decisions. These results collectively suggest that EVAR may be particularly beneficial for high-risk INAAA patients unsuitable for OAR, potentially expanding treatment options for this challenging condition.

Outcomes of thoracic endovascular aortic repair for complicated type B acute aortic dissection from a multicenter Japanese post-market surveillance study.

A primary goal of thoracic endovascular aortic repair (TEVAR) for type B acute aortic dissection (BAAD) is exclusion of the primary entry tear with a suitable stent graft (SG) to reestablish true lumen flow and promote aortic remodeling. This study aimed to determine the safety and efficacy of a conformable thoracic SG in a Japanese population with complicated BAAD. Between 2016 and 2017, 43 patients with complicated BAAD were enrolled in this prospective, nonrandomized, multicenter post-market surveillance study at 27 sites in Japan. All patients underwent TEVAR using the Gore TAG Conformable Thoracic Endoprosthesis (CTAG) (W.L. Gore and Associates, Flagstaff, AZ). The most common TEVAR indication for complicated BAAD was malperfusion (41.9%; 24 out of 43) and aortic rupture was observed in 32.5% of patients (14 out of 43). All SG implants were successfully completed and there was no patient with surgical conversion. Thirty-day mortality was 7.0% (3 out of 43) and one patient (2.3%) experienced spinal cord ischemia during hospitalization. Entry tear exclusion was achieved in 91.3% of patients at 1month, and 95.7% at 24months. Through 24months after TEVAR, no retrograde type A aortic dissection was observed and distal stent graft induced new entry was observed in two patients (4.7%). TEVAR utilizing the CTAG device for complicated BAAD in Japan demonstrated a low incidence of perioperative mortality and complications. Complications directly attributed to the SG including RTAD and dSINE were uncommon and the midterm outcomes were deemed satisfactory.

Safety and Efficacy of Coil Embolization for Endoleak Prevention as an Adjunct to Endovascular Repair of Abdominal Aortic Aneurysm or Subsequently for Repair of Endoleak

This study assessed the real-world safety and efficacy of coil embolization during endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) for prophylactic endoleak prevention or as a reintervention for endoleak repair, using the Cerenovus family of coils (Cerenovus, Irvine, CA, USA). This was a multicenter, retrospective cohort study of consecutive patients who underwent embolization of branching arteries during EVAR of an AAA or as a reintervention for endoleak repair, using Cerenovus coils between January 2017 and December 2021 in Japan. The primary outcome was 30-day reintervention-free survival, defined as cardiovascular mortality or any complication requiring reintervention within 30days post procedure. Secondary outcomes included conversion to open surgical repair, length of hospitalization, and the following outcomes through 30days and 1-year post procedure: occurrence of endoleak (Type I-V), reintervention, complications not requiring reintervention, aneurysm-related mortality, coil migration, and all-cause mortality. A total of 306 patients (mean age 76.7±7.8; 16.7% [51/306] female) were included in the study. Infrarenal AAA were most common (175/306; 57.2%), and the mean aneurysm size was 52.1±10.9mm. At 30days, reintervention-free survival was achieved in 96.4% (295/306) of the patients; 9 (2.9%) patients required reintervention, and 2 (0.7%) died from cardiovascular causes through 30days. One (1/305; 0.3%) patient underwent conversion to open repair. The mean length of hospitalization was 8.6±7.2days. Complications not requiring reintervention occurred in 3.9% (12/306) of the patients through 30-days and 12.4% (38/306) through 1-year. Endoleak occurred in 2.9% (9/306) of the patients at 30days and 9.5% (29/306) at 1year. Coil migration and aneurysm rupture were not reported for any patient. Aneurysm-related mortalities occurred in 0.0% (0/305) at 30days and 0.3% (1/303) at 1year. All-cause mortalities occurred in 0.7% (2/306) at 30days and 3.3% (10/304) at 1year. This study demonstrated that the use of Cerenovus coils yielded a high rate of 30-day-reintervention-free survival and low rates of type II endoleak occurrence and recurrence at the target vessel through 30days and 1year in patients following EVAR of an AAA with coil embolization, either for prophylactic endoleak prevention during EVAR or as a reintervention to repair an endoleak.

Factors Associated with Increased Fluoroscopy Time During Elective Endovascular Abdominal Aortic Aneurysm Repair and its Utilization as an Indicator of Intraoperative and Postoperative Outcomes

ObjectivesThis study explores the impact of prolonged fluoroscopy time (FT) on outcomes in endovascular aortic repair (EVAR) for abdominal aortic aneurysms (AAA). While total operative time includes multiple variables, FT precisely captures the technical precision of the EVAR procedure. By examining the factors that extend FT, we aim to establish FT as a critical quality metric for evaluating surgical performance and predicting postoperative outcomes. MethodsA retrospective review of the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) was conducted (2003-2021). The FT was studied based on a median dichotomy of ≤18 mins (Group I) and >18 mins (Group II). Primary outcomes of in-hospital mortality and discharge status were studied, along with numerous secondary outcomes pertaining to systemic complications. Factors associated with more extended FT were also measured. All the variables examined in multivariate analyses were estimated in odds ratios, and a p-value of <0.05 was deemed significant for all the analyses performed. Results41,841 patients were studied, of which 20,339 were categorized in Group I and 21,502 in Group II. The average fluoroscopy time in the selected patients was reported to be 23.2 minutes. Patients in Group II generally had overall poorer health status with multiple comorbidities and on various medications. Aortic aneurysm parameters can influence the FT, including the greater aorta-neck angle, neck angle, neck diameter, and neck length. Patients treated by high-volume surgeons were observed to have less likelihood of prolonged FT. On trends analysis, it was observed that the FT has been consistent over the study period. ConclusionVarious factors can influence the FT in patients undergoing EVAR, including the patient characteristics and the complexity of the aneurysm. Identifying the risk factors associated with prolonged FT can help prepare the surgeons and devise ways to ensure a high quality of care, better risk stratification, and enhanced safety, especially for more prolonged exposure to radiation and contrast volumes.

Open thoracic aortic aneurysm sac exploration following thoracic endovascular aortic repair and fenestrated branched endovascular aortic repair: New hybrid approach to fixing the Achilles heel of endovascular repair, while raising new questions.

Open thoracic aortic aneurysm sac exploration following thoracic endovascular aortic repair and fenestrated branched endovascular aortic repair: New hybrid approach to fixing the Achilles heel of endovascular repair, while raising new questions.

Evaluating the Proposal of the European Society for Vascular Surgery Abdominal Aortic Aneurysm Guidelines to Stratify Surveillance after Endovascular Aortic Aneurysm Repair in a Single Centre.

The aim of this study was to evaluate and compare methods that identify patients at low risk of developing complications after endovascular aortic aneurysm repair (EVAR) and thus would not require surveillance in the first post-operative years. This was a retrospective, single centre, cohort study including all patients after elective infrarenal EVAR with both immediate post-operative and one year computed tomography angiography (CTA) imaging. Patients were categorised by adherence to instructions for use (IFU), adequate seal, and absence of endoleak (method A1), and without high risk features (method A2) on the first post-operative CTA. Additionally, these patients were dichotomised based on aneurysm sac shrinkage at one year (> 5 mm maximal diameter reduction, method B). Outcomes were graft related adverse events and all cause death. Negative predictive value (NPV) was utilised to compare risk classifications. Of 422 eligible patients, 297 underwent the required imaging for classification: 140 (47.1%) and 109 (36.7%) patients were classified as low risk based on methods A1 and A2, respectively, while 147 (49.5%) were assumed low risk based on method B. The five year cumulative incidence of adverse events in low risk patients according to method A1 was 14.6% (95% confidence interval [CI] 8.5 - 20.9%), similar to method A2 (16.1%, 95% CI 8.8 - 23.4%) and method B (15.4%, 95% CI 9.3 - 21.5%). The five year median NPV for adverse events of method A1 was 85.2% (95% CI 79.7 - 90.8%), comparable with method A2 (83.8%, 95% CI 76.9 - 90.3%; p = .37) and method B (84.7%, 95% CI 79.4 - 89.5%; p = .87). Significantly higher NPVs were found by combining method A1 or A2 with method B, with median values ≥ 95% up to four years after EVAR. The five year NPV for death did not differ between methods (five year NPVmethod A1, 81.7%, 95% CI 76.6 - 86.5%). Refraining from imaging in the first five years after EVAR in patients treated within IFU and with a favourable post-operative CTA would have failed to detect important complications at an early stage. It is proposed to combine the post-operative CTA and sac shrinkage at one year in order to stratify post-EVAR surveillance. No benefit was found in considering the high risk features suggested in the European Society for Vascular Surgery (ESVS) guidelines.

Evaluation of aortic stent endoleaks in the renally impaired patient with ferumoxytol-enhanced MR angiography.

To evaluate ferumoxytol-enhanced magnetic resonance angiography (FE-MRA) for assessment of endoleaks in patients with abdominal aortic aneurysms (AAA) and chronic kidney disease (CKD) status post endovascular aneurysm repair (EVAR). Of 1854 patients who underwent FE-MRA at a single institution between 03/21/2014 and 08/21/2023, 21 patients with a history of AAA and CKD status post EVAR were retrospectively identified (IRB #13-001341). Multiplanar pre- and post-contrast HASTE, T1-VIBE, and high-resolution breath-held 3D MRA sequences were obtained, where a dose of 4mg/kg of Ferumoxytol was infused over six minutes. All examinations were performed on either a Siemens 3.0T Prisma Fit, a Siemens 3.0T TIM Trio, or a Siemens 1.5T Avanto MRI scanner. Image post-processing was performed using OsiriX and Vitrea software for endoleak identification and display. Twenty-six FE-MRA examinations were completed, where 24 were fully diagnostic and 2 were limited by metal artifact. Three patients underwent one follow-up examination, while one patient underwent two follow-up examinations. Endoleaks were identified in seven patients: one Type Ia, two Type Ib, and four Type II. The Type Ia endoleak patient received follow-up imaging two years after initial imaging. A Type II endoleak patient received follow-up imaging six months and one year after initial imaging. In both cases, the Type I and Type II endoleaks were reproducibly visualized. No contrast reactions occurred. For patients with a history of AAA and CKD status post EVAR, FE-MRA is a safe, practical and effective imaging solution for evaluation of Type I and Type II endoleaks.

Don’t mix it up! Long-term outcomes of different proximal aortic cuffs with the AFX endograft

The AFX unibody endograft offers advantages in treating abdominal aortic aneurysms (AAAs) with narrow aortic bifurcations due to its unique design, where the flow divider sits at the native aortic bifurcation. However, its limited length options may limit complete proximal neck utilization. As per device instruction for use, the implant should be completed with an aortic cuff. This study aims to evaluate the long-term outcomes of patients treated with an all-Endologix implant versus a combination of Endologix and Medtronic devices. This retrospective, single-center study included 134 consecutive AAA patients who underwent endovascular aneurysm repair (EVAR) using the AFX unibody endograft paired with suprarenal aortic cuffs from Endologix (n=86) or Medtronic (n=48) between November 2011 and November 2022. Patients were divided into 2 groups based on the type of aortic cuff used. The primary outcome was the occurrence of type 3A endoleaks at the longest available follow-up. Secondary outcomes included any endoleak, reintervention rates, all-cause mortality, and aneurysm-related death. The median follow-up was 41months, and type 3A endoleaks occurred after a mean 34.8months in 6 patients (4.5%), which is significantly more frequent in the mixed-device group (12.8%) (P<0.001). Type 3A endoleak occurred regardless of overlap and developed over time. Endoleaks of any type were reported in 17 patients. Reinterventions were needed in 12 patients. The use of an Endurant cuff was associated with a significantly increased risk of type 3A endoleaks (hazard ratio [HR] 16.5; 95% [CI] 1.9-143; P=0.011) and reinterventions (HR 9.67; 95% CI 1.9-49.6; P=0.006). Combining endografts from different manufacturers, especially those with differing materials and sealing mechanisms, may compromise the long-term integrity of certain EVAR repairs. Clinicians should exercise caution when considering mixed-device configurations and ensure rigorous follow-up for patients with such implants.

Endovascular Treatment of Abdominal Aortic Aneurysm with Hostile Artery Access: A Multi-Center Retrospective Study

PurposeThe objective of this study is to document our experience using low-profile endografts for the endovascular repair of abdominal aortic aneurysms (AAAs) in cases where access arteries are challenging, commonly referred to as hostile access arteries. MethodsData regarding patients with narrow or tortuous access arteries who underwent endovascular aortic repair (EVAR) using low-profile endografts at three tertiary medical centers between January 2020 and December 2022 were retrospectively collected and analyzed. A total of 76 patients were enrolled in the study. The primary endpoints included technical success, occurrence of endoleaks, endograft occlusion, and any device- or procedure-related major adverse events. Secondary endpoints were assessed for endograft migration, endograft fracture, access site complications, and aneurismal sac shrinkage. ResultsThe mean follow-up duration was 28.1±9.0 months (range, 14.0-54.0). Among the patients, 32 (42.1%) had narrow artery access (diameter ≤ 6.0 mm), 29 (38.2%) had access arteries characterized by tortuosity, and 15 (19.7%) patients presented with both narrow and tortuous access arteries. Technical success was achieved in 73 (96.1%) cases. A total of four (5.2%) patients received reintervention due to endograft occlusion. During follow-up, a total of eight (10.5%) type II endoleaks were observed during follow-up without intervention, and the endoleak disappeared in the follow-up period. Abdominal aortic aneurysm-sac shrinkage and stability were observed in 25 (32.9%) and 51 (67.1%) cases, respectively. The overall survival rate was 98.7%. The perioperative and follow-up outcomes for the groups categorized by ‘Narrow arteries’, ‘Tortuous arteries’, and ‘Narrow and Tortuous arteries’ did not show statistically significant differences when compared to each other. ConclusionThis preliminary investigation indicates that the use of low-profile endografts is associated with safety and effectiveness within the observed period.

Surgeon Volumes of Endovascular Thoracoabdominal Aneurysm Repairs, but not Juxtarenal Repairs, are Associated with Outcomes following Endovascular Repair of Thoracoabdominal Aneurysms.

Endovascular thoracoabdominal aortic aneurysm (eTAAA) repair remains one of the more technically challenging aspect of vascular surgery, with significant risk of mortality, spinal cord ischemia (SCI), and end organ damage. Although fenestrated devices are available for juxtarenal aneurysms, there are no commercially available eTAAA devices on the US market currently. We therefore studied how the volume of juxtarenal repairs would translate to outcomes of these more complicated aneurysms. We studied all eTAAA repairs (Crawford type 1-3) in the Vascular Quality Initiative from 2014-2021 and categorized surgeons into quartiles based on their average annual eTAAA volume and endovascular juxtarenal volume. Our primary outcome was thoracoabdominal life altering events (TALE-composite of perioperative death, stroke, permanent SCI and dialysis). We employed mixed effects logistic regression clustering by center and surgeon. We identified 5335 repairs from 607 surgeons, with annual average eTAAA volumes of 2,629 from 400 surgeons. Quartile 1 involved <2 repairs and quartile 4 involved >12 repairs per year. Repairs at higher quartiles were for larger aneurysms, more commonly employed staged repairs, utilized spinal drains, and more frequently utilized physician modified endografts, whereas low volume surgeons most commonly employed parallel grafting. Higher volume surgeons had overall shorter procedural times, fluoroscopy time, and less total contrast. Technical success similarly increased as procedure volume increased. In adjusted analyses, rates of perioperative death, TALE, stroke, acute kidney injury and major adverse cardiac events were all lower in the highest volume quartile compared to the lowest. However, after accounting for eTAAA volume, surgeon volume of endovascular juxtarenal repairs was not associated with any postoperative outcome, and there was no significant interaction between juxtarenal and eTAAA volume. Medium term mortality was lowest in patients treated in the top two quartiles of volume (HR 0.77 [0.61-0.97], P = .024. Surgeon eTAAA experience shows a strong volume-outcome effect on outcomes in the immediate post operative period and in permanent patient-centered outcomes. However, experience in less extensive aneurysms did not directly translate to thoracoabdominal aneurysms. Further study is needed to evaluate the role that commercial graft availability and repair type contributes to these findings.

Effect of Family History of Aortic Disease on Outcomes of Fenestrated and Branched Endovascular Aneurysm Repair of Complex Aortic Aneurysms

Effect of Family History of Aortic Disease on Outcomes of Fenestrated and Branched Endovascular Aneurysm Repair of Complex Aortic Aneurysms