Increased Sac Size Research Articles

Safety and Validity of the Proposed European Society for Vascular Surgery Infrarenal Endovascular Aneurysm Repair Surveillance Protocol: A Single Centre Evaluation

Long term surveillance after endovascular aneurysm repair (EVAR) is essential to detect late complications, but there is variation in practice. The European Society for Vascular Surgery (ESVS) made a recommendation for a new surveillance protocol; one element involves risk stratifying patients depending on sac size reduction and presence of endoleak at their 30 day computed tomography angiogram into low risk groups (delayed imaging to five years) or higher risk groups (continue with the current protocol). The aim was to test this suggested protocol retrospectively within an EVAR patient cohort. Data on EVARs performed from October 2009 to October 2019 were collected. Information gathered from an existing surveillance programme was used to assess the proposed ESVS protocol. All patients who underwent re-intervention were reviewed to see whether adopting the proposed ESVS protocol would have detected these events. In total, 309 procedures were included. Altogether, 219 of these patients had no endoleak (70.9%) and 86 had a type II (27.8%) endoleak. Only four developed a type I or III endoleak. No patient in the low risk cohort (no initial endoleak or sac shrinkage > 1 cm) required secondary intervention. Five year follow up data were available for 103 patients. In the type II endoleak group, there were 28 secondary interventions in 22 patients. No patient experienced a ruptured aneurysm within five years post-operatively. Had the proposed ESVS protocol been followed, all patients requiring a secondary intervention or with increasing sac size would have been detected/captured. Further, adherence to the ESVS guidelines would have resulted in 103 patients with a five year follow up history qualifying for reduced surveillance. A further 120 patients who had reached the three and four year follow up timepoints could have qualified for a reduced surveillance, reducing imaging cost further. Adopting the proposed ESVS EVAR surveillance protocol safely identified “low risk” patients who did not go on to require a secondary intervention. These patients could benefit from reduced surveillance scanning.

Safety and Validity of the Proposed European Society for Vascular Surgery Infrarenal Endovascular Aneurysm Repair Surveillance Protocol: A Single Centre Evaluation

Long term surveillance after endovascular aneurysm repair (EVAR) is essential to detect late complications, but there is variation in practice. The European Society for Vascular Surgery (ESVS) made a recommendation for a new surveillance protocol; one element involves risk stratifying patients depending on sac size reduction and presence of endoleak at their 30 day computed tomography angiogram into low risk groups (delayed imaging to five years) or higher risk groups (continue with the current protocol). The aim was to test this suggested protocol retrospectively within an EVAR patient cohort. Data on EVARs performed from October 2009 to October 2019 were collected. Information gathered from an existing surveillance programme was used to assess the proposed ESVS protocol. All patients who underwent re-intervention were reviewed to see whether adopting the proposed ESVS protocol would have detected these events. In total, 309 procedures were included. Altogether, 219 of these patients had no endoleak (70.9%) and 86 had a type II (27.8%) endoleak. Only four developed a type I or III endoleak. No patient in the low risk cohort (no initial endoleak or sac shrinkage > 1 cm) required secondary intervention. Five year follow up data were available for 103 patients. In the type II endoleak group, there were 28 secondary interventions in 22 patients. No patient experienced a ruptured aneurysm within five years post-operatively. Had the proposed ESVS protocol been followed, all patients requiring a secondary intervention or with increasing sac size would have been detected/captured. Further, adherence to the ESVS guidelines would have resulted in 103 patients with a five year follow up history qualifying for reduced surveillance. A further 120 patients who had reached the three and four year follow up timepoints could have qualified for a reduced surveillance, reducing imaging cost further. Adopting the proposed ESVS EVAR surveillance protocol safely identified "low risk" patients who did not go on to require a secondary intervention. These patients could benefit from reduced surveillance scanning.

Surgical Management of Occipital Encephaloceles, Series of 14 Patients

Abstract Background: Encephalocele is a congenital anomaly of the central nervous system characterized with herniation of cranial contents outside the brain through a bony skull defect. Objective: The aim of this study is to present our experi-ence, technique and results of 14 patients with occipital encephaloceles managed surgically at Banha University over 4 years period. Material and Methods: 14 patients who were diagnosed with occipital encephaloceles and referred to our Neurosurgery Department at Banha University between 2015 and 2019 were enrolled in this study. The clinical findings, radiological findings, perioperative management and surgical outcome were assessed. Results: In the study, 14 patients (10 girls, 4 boys), whose age varied between newborn and 2 months, were evaluated. The size of the sac ranged from (2cm X 3cm) to (10cm X 13cm). Surgery was performed for all patients, 2 (14.2%) of the 14 patients died. The morbidity rate in our study was (31.2%) in the form of developed hydrocephalus, CSF leak and infection. Conclusion: Occipital encephalocele is commonly seen congenital anomaly in the practice of pediatric neurosurgery. Modern neuroimaging, neurosurgical techniques and periop-erative care have greatly improved the management and outcome of occipital encephalocele. Increased sac size, hydrocephalus, presence of neural tissue in the sac content and associated congenital anomalies are accompanied with bad outcome.

Velocities of type II endoleaks on Doppler ultrasonography predict outcome

ObjectiveWe sought to determine whether flow velocities measured using Doppler ultrasonography after endovascular aortic aneurysm repair (EVAR) can predict for resolution of type II endoleaks without intervention. We also assessed the relationship of the flow velocities to sac growth and the need for intervention. We hypothesized that hemodynamic properties suggesting low flow velocity would predict for resolution of type II endoleaks. MethodsThe data from 23 patients with type II endoleaks identified on Doppler ultrasonography after EVAR from January 2014 to December 2017 were retrospectively analyzed. The 23 patients with type II endoleaks were split into two groups. Group 1 included the 13 patients with resolved endoleaks or shrinking sac size and group 2, the 10 patients with an increasing sac size or those requiring intervention to seal the endoleak because of an increased sac size. We analyzed the velocities of the endoleak nidus. ResultsDoppler ultrasound velocities were significantly lower in patients with resolved type II endoleaks and those with a shrinking aneurysm sac size compared with those demonstrating an increase in aneurysm sac size (42.6 ± 25.2 cm/s vs 219.5 ± 84.1 cm/s; P < .0001). Of the 10 patients in group 2, nine had required intervention with either translumbar embolization or transarterial embolization, with only two experiencing complete resolution of the type II endoleak, despite the intervention. All patients in group 2 had had ≥1 duplex ultrasound scan with endoleak nidus velocities >100 cm/s. In contrast, no patient in group 1 had had any duplex ultrasound scan with endoleak nidus velocities >100 cm/s. ConclusionsThe Doppler ultrasound velocities of type II endoleaks might be able to predict for spontaneous resolution of type II endoleaks or increased sac growth. Type II endoleaks on Doppler ultrasonography with endoleak nidus velocities >100 cm/s can persistent, even with attempted treatment.

Fate of Pure Type II Endoleaks Following Endovascular Aneurysm Repair.

PurposeType II endoleaks (T2ELs) are the most common type of endoleaks observed after endovascular aneurysm repair (EVAR). However, whether T2ELs should be treated remains debatable. In the present study, we aimed to describe the natural course of T2ELs and suggest the direction of their management.Materials and MethodsWe reviewed the data of 383 patients who underwent EVAR between 2007 and 2016. Data, including demographic and anatomical details, were collected, and patients with T2ELs were compared to those without them. Patients with T2ELs were categorized into subgroups according to changes in sac size and treatment requirement.ResultsWe found patent lumbar artery count and lesser thickness of mural thrombi to be significant risk factors for T2ELs. Among the 383 patients, 85 (22.2%) patients were diagnosed with pure T2ELs. Among these 85 patients, the sac size increased in 29 (34.1%) patients, showed no significant change in 39 (45.9%) patients, and decreased in 17 (20.0%) patients. Fifteen (17.6%) patients, among 85 with initial pure T2ELs, showed spontaneous resolution. Five (5.9%) patients among 29, in whom the sac size increased, developed combined-type endoleaks. No sac ruptures were noted among the patients with T2ELs.ConclusionT2ELs with sac expansion potentially contribute to other types of endoleaks. Therefore, periodic screening is important for these patients, particularly for those showing an increasing sac size. In addition, intervention should be considered when other types of endoleaks occur.

Explant of aortic stent grafts following endovascular aneurysm repair.

Background Failure of endovascular aneurysm repair may require explant of the stent graft in a subset of patients. We sought to assess outcomes in a cohort of patients undergoing explant of endovascular aneurysm repair in both emergency and elective settings. Methods Patients undergoing explant of endovascular aneurysm repair were identified from a prospectively maintained database, with additional information obtained through retrospective analysis of medical records. Results Over a 21-year period, 1997–2018 (May), there were 597 endovascular aneurysm repair procedures performed in our institution for abdominal aortic aneurysm. There were 19 endovascular aneurysm repair explants; five of these were referrals from other vascular centres. The median age was 73 years (range 46–81). The median length of time from insertion to explant was 39.2 months (range 0–153). Indications for elective explant were type Ia endoleak (n = 4), type 1b endoleak (n = 1), type II endoleak with increasing sac size (n = 1), type I/III endoleak (n = 1), type IV endoleak (n = 1), and increasing sac size without evident endoleak (type V, n = 2). The remaining nine cases were emergency procedures, with four patients presenting with rupture post endovascular aneurysm repair, four patients presenting with acute stent thrombosis, of which one also had a type 1a endoleak and one aorto-enteric fistula. There were no mortalities in the elective group and three mortalities in the emergency group (0 vs 33.3%, p = 0.087). Overall 30-day mortality was 15.8% Conclusion Explant of aortic stent grafts can be associated with high mortality and morbidity rates, especially in the emergent setting. Patient and device selection and post-operative surveillance remain vitally important to optimise outcomes post endovascular aneurysm repair.

Effect of flow diversion with silk on aneurysm size: A single center experience.

Alterations in aneurysm size and mass effect can result in alleviation or aggravation of symptoms. We assessed the effects of flow diversion with SILK stents on aneurysm sac size and associated factors. A retrospective evaluation of 14 aneurysms treated with SILK stents alone with MRI follow-up was performed. Aneurysm sac size was measured using the sequence best demonstrating the sac. Aneurysm characteristics and flow-related enhancement on time of flight images were documented. Clinical histories were reviewed for evolution of symptoms. Complete collapse of the aneurysm sac was demonstrated at three and 18 months in 2/14 aneurysms. Increase in size was observed in 2/14 aneurysms with associated persistent flow on time of flight MRA. Blister formation with aggravation of symptoms was observed in one aneurysm, and subsequent decrease in size occurred after treatment with a second SILK. The other aneurysm which increased in size initially continued to enlarge asymptomatically despite retreatment with a second SILK, however at 24 months thrombosis of the sac and decrease in size was observed. The remaining 10/14 aneurysms decreased in size. Nine had corresponding MRA occlusion and the tenth demonstrated decreased but persistent flow on the time of flight MRA. No aneurysm with MRA occlusion increased in size. Decrease in sac size was associated with MRA occlusion in our study. Persistence of flow and blistering were associated with increased sac size. As previously demonstrated flow diversion may be effective in the treatment of large aneurysms presenting with mass effect, however rates of sac obliteration in this small series were not as high as previously reported.

One-Year Results of the Multilayer Flow Modulator Stent in the Management of Thoracoabdominal Aortic Aneurysms and Type B Dissections

To report 1-year results from the first subgroup of patients treated with the Multilayer Flow Modulator (MFM) stent for aortic aneurysm and dissection. Up to December 2012, 243 patients have been treated worldwide for aortic aneurysm and dissection with the Cardiatis MFM under the established indications for use. This retrospective review encompasses the first 55 of these patients (41 men; mean age 64.5±18 years), who were treated on a compassionate basis in 11 countries. There were 31 thoracoabdominal aortic aneurysms (8 Crawford type I, 3 type II, 9 type III, and 11 type IV), 7 arch aneurysms, 3 infrarenal abdominal aortic aneurysms, 8 suprarenal aortic aneurysms, and 6 type B dissections. Mean aneurysm diameter was 6.04±1.66 cm, and the mean length was 11.58±7.62 cm. The primary endpoint at 1 year was a composite of rupture and aneurysm-related death. The secondary endpoints were all-cause mortality, visceral branch occlusion, adverse events (i.e., stroke and paraplegia), and reintervention. Technical success was 98.2%; there was no paraplegia or perioperative visceral or renal insult. The mean number of side branches covered was 3.7±1.3 per case (range 0-6); 108 stents were deployed (range 1-5). At 1 year, aneurysm-related survival was 93.7%, all-cause survival was 84.8%, intervention-free survival was 92.4%, and all of the 202 side branches were patent. There were no stent fractures. At 6 months, the mean rate of sac volume increase was 0.36% per month, resulting in a mean volume increase of 2.14%. At 12 months, the rate of increase had slowed to 0.28% per month, resulting in a total average increase in sac volume of 3.26%. The ratio of thrombus to total volume stayed almost constant over the 12 months at 0.48, while the ratio of flow to total volume fell from 0.21 to 0.12 at 12 months. MFM implantation instigates a process of aortic remodeling involving initial thrombus deposition, which slowed between 6 and 12 months. Increasing sac size did not herald rupture, and the MFM was not associated with loss of native side branches. With physiological modulation of the aneurysm, the MFM offers promise for resolution of complex thoracoabdominal pathology with off-the-shelf availability, but this disruptive technology requires further development and technical refinement. Long-term follow-up of the registry patients is mandatory before establishing a randomized controlled study.

The “fenestrated inside fenestrated” stent graft solution for therapy-resistant type Ia endoleak after fenestrated endovascular aortic aneurysm repair

Endoleaks combined with increasing sac size following endovascular aneurysm repair require reintervention to prevent secondary aneurysm rupture. For standard infrarenal stent grafts, there are multiple treatment strategies available. However, in the presence of a fenestrated or branched stent graft, options are limited. We describe a novel challenging approach to treat a persistent type Ia endoleak by placing a second fenestrated stent graft into the pre-existing one, thus, realigning the graft and extending the proximal sealing zone.

Fate of Popliteal Artery Aneurysms After Exclusion and Bypass

Treatment of popliteal aneurysm (PA) includes exclusion and bypass graft. In excluded sac, persistent flow through collateral arteries (endoleak) could result in aneurysm growth. We retrospectively reviewed PA treated by exclusion and bypass, using duplex ultrasound or computed tomography (CT) scans to demonstrate the presence of residual flow and sac growth. Between 1997 and 2007, we treated 53 PAs in 46 patients by ligation and bypass grafting using polytetrafuoroethylene (PTFE) or saphenous vein. The mean PA diameter preoperatively was 33.4 mm (range, 20-70 mm). At a mean follow-up period of 35 months, 75% (n = 40) PA showed a decrease in mean transverse diameter, from 33.4 to 27.3 mm (p < 0.001). In 17% patients (n = 9), aneurysm sac size remained unchanged, whereas in 8% (n = 4) it increased (mean, 4.5 mm). In six cases (11%), persistent sac flow was revealed by Duplex or TC scan. One patient with a large aneurysm that increased by 50% underwent endoaneurysmorrhaphy through a posterior approach because of symptoms related to local compression. No rupture occurred in follow-up period. The cumulative Kaplan-Meier patency rate at 12, 36, and 60 months were 86%, 76%, and 69%, respectively. Limb salvage rate at 5 years was 92%. Cumulative patency rate at 60 months in the group with popliteal artery unchanged or increased resulted significantly lower than the group with aneurismal sac decreased (30% vs. 84%; p < 0.001). Multivariate analysis did not show correlation between risk factors or preoperative aneurysm diameter, and increased or decreased sac size. In our results, aneurysm sac growth exists but is low, and a persistent sac flow was not correlated to increased sac size. In view of these results, we believe that medial approach for popliteal artery reconstruction can be used because the aneurysm increase is low and the risk of rupture is not important. No decrease of sac size was otherwise significantly correlated to graft patency.

Duplex ultrasound in aneurysm surveillance following endovascular aneurysm repair: a comparison with computed tomography aortography

Cumulative radiation dose, cost, and increased demand for computed tomography aortography (CTA) suggest that duplex ultrasonography (DU) may be an alternative to CTA-based surveillance. We compared CTA with DU during endovascular aneurysm repair (EVAR) follow-up. Patients undergoing EVAR had clinical and radiological follow-up data entered in a prospectively maintained database. For the purpose of this study, the gold standard test for endoleak detection was CTA, and an endoleak detected on DU alone was assumed to be a false positive result. DU interpretation was performed independently of CTA and vice versa. One hundred thirty-two patients underwent EVAR, of whom 117 attended for follow-up ranging from six months to nine years (mean, 32 months). Adequate aneurysm sac visualisation on DU was not possible in 1.7% of patients, predominantly due to obesity. Twenty-eight endoleaks were detected in 28 patients during follow-up. Of these, 24 were initially identified on DU (four false negative DU examinations), and eight had at least one negative CTA with a positive DU prior to diagnosis. Twenty-three endoleaks were type II in nature and three of these patients had increased sac size. There was one type I and four type III endoleaks. Two of these (both type III) had an increased sac size. Of 12 patients with increased aneurysm size of 5 mm or more at follow-up, five had an endoleak visible on DU, yet negative CTA and a further five had endoleak visualisation on both DU and CTA. Of six endoleaks which underwent re-intervention, all were initially picked up on DU. One of these endoleaks was never demonstrated on CTA and a further two had at least one negative CTA prior to endoleak confirmation. Positive predictive value for DU was 45% and negative predictive value 94%. Specificity of DU for endoleak detection was 67% when compared with CTA, because of the large number of false positive DU results. Sensitivity for DU was 86%, with all clinically significant endoleaks demonstrated on CTA also detected on DU. Despite its low positive predictive value, we found DU to be a sensitive test for the detection of clinically significant endoleaks. Given concerns about cumulative radiation exposure and cost, and the surprisingly low sensitivity of CTA for endoleak detection in this series, selective CTA based on DU surveillance may be a more appropriate long-term strategy.

Fate of Endoleaks Detected by CT Angiography and Missed by Color Duplex Ultrasound in Endovascular Grafts for Abdominal Aortic Aneurysms

To analyze the clinical implications of endoleaks documented by computed tomographic angiography (CTA) and missed by color duplex ultrasound (CDU). During a recent 5-year period, 232 patients underwent endovascular aortic reconstruction (EVAR) and were followed according to a protocol that included CTA and CDU at 1 month and every 6 months thereafter. CTA was the gold standard for determining the presence of endoleaks. The size of the AAA sac at the latest postoperative follow-up was compared to the preoperative size and correlated to the type of endoleak and clinical outcome. This study analyzed only patients with endoleak documented by CTA and CDU and specifically analyzed the outcome of patients with false negative CDU studies for endoleaks. Thirty-nine endoleaks were documented in 35 (15%) of 232 patients using CTA. Four patients had both early and late endoleaks. The mean follow-up was 25 months (range 1-64). CDU was more helpful in detecting type I endoleaks than type II endoleaks (89% versus 58%, p<0.05). There were 18 (46%) type I endoleaks (12 early, 6 late) detected by CTA; 16 (89%) of these were detected by CDU (2 late endoleaks missed). Nineteen (49%) type II endoleaks (16 early, 3 late) were diagnosed using CTA, 11 (58%) of which were detected by CDU (6 early and 2 late missed). Of the 2 (5%) early type IV endoleaks found on CTA, 1 (50%) was missed by CDU. Overall, CDU failed to identify endoleak in 11 (28%) of 39 endoleaks [2 late type I, 8 type II (6 early, 2 late), and 1 early type IV]. Consequences to treatment occurred in 2 (20%): 1 type I endoleak required treatment and 1 type II endoleak would have missed treatment. CDU has a lower sensitivity in detecting endoleak, particularly type II; therefore, EVAR surveillance should not be based solely on CDU. Although a significant number of type II endoleaks resolved spontaneously, intervention can be offered for type II endoleaks if associated with an increasing sac size.

Outcome of popliteal artery aneurysms after exclusion and bypass: Significance of residual patent branches mimicking type II endoleaks

Popliteal aneurysms (PAs) often are treated with exclusion and bypass. However, excluded aneurysms can transmit systemic pressure from persistent flow through collateral arteries (endoleak), resulting in aneurysm growth and rupture. We used duplex ultrasound scanning for postoperative surveillance more than 2 years after PA repair with exclusion and bypass, to determine the presence of flow and aneurysm growth. From 1995 to 2001, 23 patients with 26 PAs (mean diameter, 3.2 cm; range, 1.6-5.6 cm) underwent surgical repair and were available for more than 2 years of follow-up. The popliteal artery was ligated proximal and distal to the aneurysm, and autogenous revascularization was performed. All patients who underwent PA endoaneurysmorrhaphy through a posterior approach were excluded from the study. During long-term follow-up, aneurysm sac flow and size were evaluated with duplex ultrasound scanning, computed tomography, or magnetic resonance angiography, and standard angiography. Patients with increased PA size and persistent flow were offered repair through a posterior approach. Over 7 years, 26 PAs (symptomatic, 11; asymptomatic, 15) treated with aneurysm exclusion and bypass were available for more than 2 years of follow-up (mean, 38 months; range, 24-78 months). In the postoperative period 16 PAs (62%) became thrombosed, 10 (38%) had persistent collateral flow through geniculate vessels, 6 (23%) increased in size, and 3 (12%) ruptured; 1 (4%) resulted in limb loss. Operative findings for all ruptured PAs and 3 of 6 PAs with increased sac size that underwent aneurysm sac exploration and endoaneurysmorrhaphy revealed retrograde flow through geniculate vessels, mimicking type II endoleak. These findings question the effectiveness of PA exclusion through proximal or distal ligation and bypass. In addition, retrograde flow into the aneurysm sac (ie, type II endoleak after endovascular abdominal aortic aneurysm repair) may transmit systemic pressure that can result in aneurysm rupture. We recommend PA treatment with aneurysm sac decompression and ligation of geniculate vessels whenever possible and routine postoperative surveillance of the excluded aneurysm sac.

A Direct Approach for the Correction of Persistent Endoleak: a Technical Report

Endovascular repair of infrarenal abdominal aortic aneurysms is becoming more widespread, with the use of a variety of different devices. They all share a subsequent risk of endoleak, which averages 25%. Type I leaks and type II leaks with increasing sac size should ideally be treated endovascularly. Embolisation through collaterals into the sac is not always achievable. We describe a case of a type II endoleak where a direct puncture of the endoleak cavity was carried out under fluoroscopy, with subsequent embolisation using Spongistan and thrombin glue to occlude the leak.

Can inhibition of carbachol or substance p-induced selective release from dura mast cells be' associated with analgesia?

Popliteal aneurysms (PAs) often are treated with exclusion and bypass. However, excluded aneurysms can transmit systemic pressure from persistent flow through collateral arteries (endoleak), resulting in aneurysm growth and rupture. We used duplex ultrasound scanning for postoperative surveillance more than 2 years after PA repair with exclusion and bypass, to determine the presence of flow and aneurysm growth.From 1995 to 2001, 23 patients with 26 PAs (mean diameter, 3.2 cm; range, 1.6-5.6 cm) underwent surgical repair and were available for more than 2 years of follow-up. The popliteal artery was ligated proximal and distal to the aneurysm, and autogenous revascularization was performed. All patients who underwent PA endoaneurysmorrhaphy through a posterior approach were excluded from the study. During long-term follow-up, aneurysm sac flow and size were evaluated with duplex ultrasound scanning, computed tomography, or magnetic resonance angiography, and standard angiography. Patients with increased PA size and persistent flow were offered repair through a posterior approach.Over 7 years, 26 PAs (symptomatic, 11; asymptomatic, 15) treated with aneurysm exclusion and bypass were available for more than 2 years of follow-up (mean, 38 months; range, 24-78 months). In the postoperative period 16 PAs (62%) became thrombosed, 10 (38%) had persistent collateral flow through geniculate vessels, 6 (23%) increased in size, and 3 (12%) ruptured; 1 (4%) resulted in limb loss. Operative findings for all ruptured PAs and 3 of 6 PAs with increased sac size that underwent aneurysm sac exploration and endoaneurysmorrhaphy revealed retrograde flow through geniculate vessels, mimicking type II endoleak.These findings question the effectiveness of PA exclusion through proximal or distal ligation and bypass. In addition, retrograde flow into the aneurysm sac (ie, type II endoleak after endovascular abdominal aortic aneurysm repair) may transmit systemic pressure that can result in aneurysm rupture. We recommend PA treatment with aneurysm sac decompression and ligation of geniculate vessels whenever possible and routine postoperative surveillance of the excluded aneurysm sac.