Infrarenal Aortic Aneurysm Repair Research Articles

Adequacy of Anesthesia Guidance for Combined General/Epidural Anesthesia in Patients Undergoing Open Abdominal Infrarenal Aortic Aneurysm Repair; Preliminary Report on Hemodynamic Stability and Pain Perception

Adequacy of Anesthesia Guidance for Combined General/Epidural Anesthesia in Patients Undergoing Open Abdominal Infrarenal Aortic Aneurysm Repair; Preliminary Report on Hemodynamic Stability and Pain Perception

Anesthesia choice for frail patients undergoing endovascular repair of non-ruptured infrarenal abdominal aortic aneurysms

BackgroundWhile general anesthesia is the predominant choice in endovascular aneurysm repair (EVAR), recent studies have suggested that locoregional anesthesia could be a viable alternative for suitable patients. Frailty has been identified as an independent predictor of elevated mortality and morbidity in EVAR. However, the choice of anesthesia in frail patients undergoing EVAR has not been explored. MethodsThis study aimed to compare the 30-day outcomes of non-emergent intact infrarenal EVAR in frail patients receiving either locoregional or general anesthesia. Patients who underwent infrarenal EVAR were identified in ACS-NSQIP database from 2012-2022. Frail patients were selected by 5-item Modified Frailty Index (mFI-5)≥2. Exclusion criteria included age<18 years, ruptured abdominal aortic aneurysm (AAA), emergency, and acute intraoperative conversion to open. A 1:1 propensity-score matching was used to match demographics, baseline characteristics, aneurysm diameter, distal aneurysm extent, and concomitant procedures between patients under locoregional and general anesthesia. Thirty-day postoperative outcomes were evaluated. ResultsAmong 16,438 patients who underwent EVAR, 4812 (29.27%) were frail. Among the frail patients, 483 (10.04%) were under locoregional anesthesia while 4,329 (89.96%) were under general anesthesia. After propensity-score matching, patients under locoregional or general anesthesia had comparable 30-day mortality (2.07% vs 2.48%, p=0.83) or any complications. ConclusionLocoregional and general anesthesia were found to have comparable postoperative outcomes in frail patients undergoing EVAR unruptured AAA, which did not align with the suggestion that locoregional anesthesia might be more advantageous in frail patients. While the patient’s preferences should be considered, the choice of anesthesia should still be individualized to take into account the patient’s age, comorbidities, AAA anatomy and the complexity of the case, as well as previous surgical and anesthesia experiences.

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

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

Preoperative anemia is a risk factor for worse 30-day outcomes in both open and endovascular repair of non-ruptured infrarenal abdominal aortic aneurysm.

Anemia is a highly prevalent condition potentially linked to chronic inflammation. Preoperative anemia is an independent risk factor across many surgical fields. However, the relationship between anemia and abdominal aortic aneurysm (AAA) repair outcomes remains unclear. This study aimed to examine the effects of preoperative anemia on 30-day outcomes of non-ruptured infrarenal AAA repair. Patients who underwent open surgical repair (OSR) and endovascular aneurysm repair (EVAR) for infrarenal AAA were identified in National Surgical Quality Improvement Program (NSQIP) targeted databases from 2012 to 2021. Anemia was defined as preoperative hematocrit less than 39% in males and 36% in females. Multivariable logistic regression was used to compare 30-day perioperative outcomes between anemic and non-anemic patients, adjusting for demographics, comorbidities, indications, aneurysm extents, operation time, and surgical approaches. There were 408 (22.13%) anemic and 1436 (77.88%) non-anemic patients who underwent OSR for non-ruptured AAA, while 3586 (25.20%) patients with and 10,644 (74.80%) without anemia underwent EVAR. In both OSR and EVAR, anemic patients had higher risks of bleeding requiring transfusion (OSR, aOR = 2.446, p < .01; EVAR, aOR = 3.691, p < .01), discharge not to home (OSR, aOR = 1.385, p = .04; EVAR, aOR = 1.27, p < .01), and 30-day readmission (OSR, aOR = 1.99, p < .01; EVAR, aOR = 1.367, p < .01). Also, anemic patients undergoing OSR had higher pulmonary events (aOR = 2.192, p < .01), sepsis (aOR = 2.352, p < .01), and venous thromboembolism (aOR = 2.913, p = .01), while in EVAR, anemic patients had higher mortality (aOR = 1.646, p = .01), cardiac complications (aOR = 1.39, p = .04), renal dysfunction (aOR = 1.658, p = .02), and unplanned reoperation (aOR = 1.322, p = .01). Moreover, in both OSR and EVAR, anemic patients had longer hospital length of stay (p < .01). In OSR and EVAR, preoperative anemia was independently associated with worse 30-day outcomes. Preoperative anemia could be a useful marker for risk stratification for patients undergoing infrarenal AAA repair.

Association between diabetes status and long-term outcomes following open and endovascular repair of infrarenal abdominal aortic aneurysms

ObjectiveCurrent literature reports conflicting findings regarding the effect of diabetes mellitus (DM) on outcomes of abdominal aortic aneurysm (AAA) repair. In this study we examined the effect of DM and its management on outcomes after open AAA repair (OAR) and endovascular AAA repair (EVAR). MethodsWe identified all patients undergoing OAR or EVAR for infrarenal AAA between 2003 and 2018 in the Vascular Quality Initiative registry data linked with Medicare claims. We excluded patients with missing DM status. Patients were stratified by their preoperative DM status, and then further stratified by DM management: dietary, noninsulin antidiabetic medications (NIMs), or insulin. Outcomes of interest included 1-year aneurysm sac dynamics, 8-year aneurysm rupture, reintervention, and all-cause mortality. These outcomes were analyzed with the χ2 test, Kaplan-Meier methods, and multivariable Cox regression analyses. ResultsWe identified 34,021 EVAR patients and 4127 OAR patients, of whom 20% and 16% had DM, respectively. Of all DM patients, 22% were managed by dietary management, 59% by NIM, and 19% by insulin. After EVAR, DM patients were more likely to have stable sacs, whereas non-DM patients were more likely to have sac regression at 1 year. Compared with non-DM, DM was associated with a significantly lower risk for 8-year rupture in EVAR (EVAR hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.51-0.92). Compared with non-DM, NIM was associated with lower risk of rupture within 8-years for both EVAR and OAR (EVAR HR, 0.64; 95% CI, 0.44-0.94; OAR HR, 0.29; 95% CI, 0.41-0.80), whereas dietary control and insulin had a similar rupture risk compared with non-DM. However, compared with non-DM, DM was associated with a higher risk of 8-year all-cause mortality after EVAR and OAR (DM vs non-DM: EVAR HR, 1.17; 95% CI, 1.11-1.23; OAR HR, 1.16; 95% CI, 1.00-1.36). After further DM management substratification, compared with non-DM, management with NIM and insulin were associated with a higher 8-year mortality in EVAR and OAR (EVAR: NIM HR, 1.12; 95% CI, 1.05-1.20; insulin: HR, 1.40; 95% CI, 1.26-1.55; OAR: NIM HR, 1.27; 95% CI, 1.06-1.54; and insulin: HR, 1.57; 95% CI, 1.15-2.13). Finally, there was a similar risk of reintervention across the DM and non-DM populations for EVAR and OAR. ConclusionsDM was associated with a lower adjusted risk of rupture after EVAR as well as OAR in patients managed with NIM. Nevertheless, just as in patients without AAA, preoperative DM was associated with a higher adjusted risk of all-cause mortality. Further study is needed to evaluate for differences in aneurysm-related mortality between DM and non-DM patients, and studies are planned to evaluate the independent effect of NIM on aneurysm-related outcomes.

Endovascular repair for infra-renal aortic aneurysms with supra-renal fixation endoprosthesis: Results and outcomes.

The main objective of this paper is to evaluate the outcomes regarding endoleaks, reinterventions, and death related to aneurysm complications in patients submitted to endovascular repair (EVAR) for abdominal aortoiliac aneurysm (AAA) using Endurant II (Medtronic) and Zenith Flex (Cook) endografts. This was a prospective, consecutive cohort study of patients with AAA who underwent EVAR with the use of Endurant II stent graft and Zenith Flex endograft. A total of 156 patients submitted to EVAR were evaluated. The perioperative mortality was 5.1%, 8 patients. The median clinical follow-up period was 760 ± 80 days. There were 28 patients (17.9%) submitted to urgent repair of the aneurysm (symptomatic expansion or rupture) and 128 patients (82.1%) submitted to elective repair. There were 36 cases (23.1%) of later endoleak and most of them are Type II endoleaks (21 patients, 13.4%). There were 12 cases of Type I endoleak. Moreover, regarding limb graft occlusion (LGO), there were 9 patients (5.8%). The overall survival rate in Kaplan-Meier analysis at 720 days was 84.8% in the total cohort. The freedom from reintervention rate in Kaplan-Meier analysis at 720 days was 92.7% in the total cohort. The linear regression analysis for survival rates showed that chronic kidney disease (p = .03; hazard ratio (HR) = 2.82, CI = 1.07-4.44) was the only factor related to poorer survival rates in both univariate and multivariate analyses. The linear regression analysis showed that the presence of endoleaks (p < .001, HR = 6.69, CI = 2.26-8.48) and limb graft occlusion (p < .001, HR = 8.02, CI = 1.60-9.99) were related to reintervention in both univariate and multivariate analyses. In this present study, supra-renal fixation endograft devices were safe and efficient in treating AAA, with satisfactory results and no renal compromise. The linear regression analysis showed that the presence of endoleaks and limb graft occlusion were related to higher reintervention rates in both univariate and multivariate analyses.

Results of the Italian Collaborators for Evar Registry on Acute Kidney Injury After Elective Endovascular Aortic Repair of Infrarenal Abdominal Aortic Aneurysm.

To analyze the incidence and predictive factors of postoperative acute kidney injury (AKI) after elective standard endovascular aortic repair (EVAR) in a large recent, multicenter cohort. This is a multicenter, retrospective, financially unsupported physician-initiated observational cohort study. Between January 2018 and March 2021, only patients treated with elective standard EVAR for infrarenal non-infected abdominal aortic aneurysm were analyzed. Patients already on hemodialysis (HD) were excluded. AKI was defined as an increase in serum creatinine (sCr) ≥0.3 mg/dL within 48 hours or an increase in sCr to ≥1.5 times baseline known or presumed to have occurred within 7 days, or a urine volume of <0.5 mL/kg/h for 6 hours. Primary outcomes of interest were AKI incidence at 30 days and freedom from HD at 1-year follow-up. Secondary outcomes were freedom from severe postoperative complication, and freedom from aorta-related mortality (ARM) at 1 year. The final cohort analyzed 526 (29.8%). There were 489 (93%) males and 37 (7%) females: the median age was 76 years (interquartile range [IQR], 71-81). Chronic kidney disease (CKD) was present in 86 (16.3%) patients. Early mortality was observed in 8 (1.5%) patients, none was aorta-related. Complication rate was 17.1% (n=89). AKI was observed in 17 (3.2%). Renal replacement therapy was needed in 4 (0.8%). HD was transitory in 2 cases and definitive in 1. Binary logistic regression analysis identified CKD (odds ratio [OR]: 4.68, 95% confidence interval [CI]: 2.10-10.45, p<0.001), and the presence of renal artery stenosis (OR: 3.80, 95% CI: 1.35-10.66, p=0.011) to be associated with an increased risk of postoperative AKI. Estimated freedom from ARM was 94.9% at 1 year. Estimated freedom from HD rate at 1 year was 94%: This was significantly different between patients with preoperative CKD and those who did not have preoperative CKD (log-rank, p=0.042). AKI after elective standard EVAR still occurs but with an acceptably low incidence rate. Preoperative CKD is the most important predictor for postoperative AKI, which was not associated with the need for HD at 1-year follow-up but with a higher propensity of mortality. This "real world" experience confirm that EVAR performed with standard contrats agent protocol remains safe for acute kidney injury development. Therefore, only patients presenting with preoperative borderline or ascertained chronic kidney disease will take the most advantage from the use of carbon dioxide contrast.

Insight from an Italian Delphi Consensus on EVAR feasibility outside the instruction for use: the SAFE EVAR Study.

The SAfety and FEasibility of standard EVAR outside the instruction for use (SAFE-EVAR) Study was designed to define the attitude of Italian vascular surgeons towards the use of standard endovascular repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA) outside the instruction for use (IFU) through a Delphi consensus endorsed by the Italian Society of Vascular and Endovascular Surgery (Società Italiana di Chirurgia Vascolare ed Endovascolare - SICVE). A questionnaire consisting of 26 statements was developed, validated by an 18-member Advisory Board, and then sent to 600 Italian vascular surgeons. The Delphi process was structured in three subsequent rounds which took place between April and June 2023. In the first two rounds, respondents could indicate one of the following five degrees of agreement: 1) strongly agree; 2) partially agree; 3) neither agree nor disagree; 4) partially disagree; 5) strongly disagree; while in the third round only three different choices were proposed: 1) agree; 2) neither agree nor disagree; 3) disagree. We considered the consensus reached when ≥70% of respondents agreed on one of the options. After the conclusion of each round, a report describing the percentage distribution of the answers was sent to all the participants. Two-hundred-forty-four (40.6%) Italian Vascular Surgeons agreed to participate the first round of the Delphi Consensus; the second and the third rounds of the Delphi collected 230 responders (94.3% of the first-round responders). Four statements (15.4%) reached a consensus in the first rounds. Among the 22 remaining statements, one more consensus (3.8%) was achieved in the second round. Finally, seven more statements (26.9%) reached a consensus in the simplified last round. Globally, a consensus was reached for almost half of the proposed statements (46.1%). The relatively low consensus rate obtained in this Delphi seems to confirm the discrepancy between Guideline recommendations and daily clinical practice. The data collected could represent the source for a possible guidelines' revision and the proposal of specific Good Practice Points in all those aspects with only little evidence available.

Wound healing and hernia after abdominal aortic aneurysm repair: Onlay self-gripping polyester mesh reinforcement compared with small bite sutured closure.

Prophylactic mesh implantation following open surgical repair of abdominal aortic aneurysm is a debatable subject. To assess the efficacy of a self-gripping polyester mesh used in on-lay technique to prevent incisional hernia after open abdominal aortic aneurysm repair. We retrospectively reviewed the records of 495 patients who underwent aortic surgery between May 2017 and May 2021. Patients included in the study underwent open surgical repair for infrarenal abdominal aortic aneurysm (AAA) with closure of the abdominal wall with either small bite suture technique or prophylactic mesh reinforcement. Primary endpoint of the study was the occurrence of incisional hernia during a two-year follow-up period. Secondary endpoints were mesh-related complications. Mesh implantation with the on-lay technique was successful in all cases. No patient in the mesh group developed an incisional hernia during the 24-month follow-up period. Two patients in the non-mesh group developed a symptomatic incisional hernia during the follow-up period at 6 months. Three cases of post-operative access site complications were observed in the mesh group. Application of a self-gripping polyester mesh using the on-lay technique demonstrates acceptable early-durability after open surgical repair of abdominal aortic aneurysms. However, it appears to be associated with a number of post-operative access site complications.

Cross-sectional, multicenter study comparing sex differences in patients undergoing endovascular repair of infrarenal abdominal aortic aneurysms. Results from the São Paulo State University Provincial Hospitals Registry (RHEUNI)

Resumo Contexto O aneurisma da aorta abdominal (AAA) afeta 4-6 vezes mais frequentemente os homens do que as mulheres, porém nas mulheres o prognóstico costuma ser pior. Objetivo Comparar os procedimentos endovasculares para correção de AAA infrarrenal em homens e mulheres, usando dados de um registro prospectivo. Métodos Esse registro foi feito em cinco hospitais universitários do estado de São Paulo entre 2012 e 2022. Foi realizado um estudo transversal, compilando dados demográficos, anatômicos (diâmetro do aneurisma, colo curto, angulado, calcificado ou com trombo; colo distal &lt; 1,5 cm e artérias ilíacas tortuosas, alteradas), complicações (vazamentos, conversões, perviedade ou estenoses de ramos) e insuficiência renal e mortalidade em 30 dias. Foram utilizados o teste de qui-quadrado e teste t de Student, com significância de 5%. O estudo foi aprovado pelo Comitê de Ética (processo 4040-2011). Resultados Um total de 152 (15,9%) dos pacientes eram mulheres e 799 (84,0%) eram homens (p &lt; 0,05). A maior parte eram brancos (80,2% das mulheres e 87,4% dos homens). Diabetes e hipertensão foram significativamente mais frequentes nas mulheres. O formato foi fusiforme, principalmente nas mulheres (95,39% versus 89,86% nos homens). O diâmetro médio foi menor nas mulheres (5,96 cm versus 6,49 cm; p = 0,0056). As artérias ilíacas foram menos envolvidas nas mulheres (89,40% versus 73,58%; p = 0,00001). A perda sanguínea foi maior nos homens (321,40 ml versus 168,84 ml nas mulheres; p &lt; 0,05). A mortalidade operatória foi similar entre os sexos, mas as obstruções foram mais frequentes nas mulheres (15,2% versus 13,51%; p = 0,017296). Conclusões Nas mulheres, o diâmetro aneurismático foi menor e as complicações obstrutivas foram mais frequentes.

Cross-sectional, multicenter study comparing sex differences in patients undergoing endovascular repair of infrarenal abdominal aortic aneurysms. Results from the São Paulo State University Provincial Hospitals Registry (RHEUNI).

Abdominal aortic aneurysms (AAA) are 4-6 times more frequent among men than among women, but prognosis tends to be worse in women. To compare endovascular procedures to repair infrarenal AAA in men and women, using data from a prospective registry. This registry collected data from five university hospitals in the state of São Paulo (Brazil) from 2012 to 2022. A cross-sectional study was conducted compiling demographic data, anatomic variables (aneurysm diameter, short neck, angulated neck, calcified neck, or thrombosed neck; distal neck < 1.5 cm, and tortuous, abnormal iliac arteries), complications (leaks, conversions, and patency or stenosis of branches) and renal failure and mortality at 30 days. The chi-square test and Student's t test were applied with a 5% significance level. The study was approved by the Ethics Committee (process 4040-2011). A total of 152 (15.9%) of the patients were women and 799 (84.0%) were men (p < 0.05). The majority were white (80.2% of the women and 87.4% of the men). Diabetes and hypertension were significantly more frequent among the women. The most prevalent shape was fusiform, particularly among the women (95.39% vs. 89.86% among men). Mean diameter was smaller among the women (5.96 cm vs. 6.49 cm; p = 0.0056). The iliac arteries were less often involved among the women (89.40% vs. 73.58%; p = 0.00001). Blood loss was greater in the men (321.40 ml vs. 168.84 ml among the women; p < 0.05). Operative mortality was similar in both sexes, but obstructions were more frequent among the women (15.2% vs. 13.51%; p = 0.017296). Aneurysmal diameter was smaller and obstructive complications were more frequent among women.

Results of elective endovascular repair of infrarenal aortic and common iliac artery aneurysms

Bevezetés: Napjainkban az infrarenalis aorta aneurysmák miatt végzett beavatkozások háromnegyede endovascularisan történik, melynél a nyitott műtéthez képest alacsonyabb perioperatív morbiditással és mortalitással, rövidebb kórházi tartózkodással, kevesebb korai szövődménnyel, de több hosszú távú komplikációval számolhatunk. Célkitűzés: A Pécsi Tudományegyetem Érsebészeti Klinikáján 2010 és 2020 között infrarenalis aorta és/vagy arteria iliaca communis aneurysma miatt végzett elektív sztentgraftbeültetések eredményeit vizsgáltuk. Módszer: Retrospektív analízisünkben a betegek demográfiai adatai, társbetegségei, a halálozás, a hospitalizációs idő és a posztoperatív intenzív osztályos megfigyelés időtartama mellett vizsgáltuk az intraoperatív, korai és késői szövődményeket, illetve a közöttük fennálló összefüggéseket. Eredmények: 274 eset került beválogatásra. Intraoperatív szövődményt 42 alkalommal (15,33%) észleltünk, 7 esetben (2,56%) endoleaket. A korai időszakban 9 (3,28%), a posztoperatív első évben 14 betegünk hunyt el (5,11%). A korai szövődmények között 3 endoleaket (1,09%) és 1 aneurysmazsák-rupturát (0,36%) detektáltunk. A sztentgraftspecifikus szövődmények közül a leggyakoribbak az endoleak voltak (n = 68, 24,82%). A vizsgálati periódus során az intenzív osztályra helyezett betegek száma és a hospitalizációs idő is szignifikánsan csökkent. Diabetes mellitus mellett szignifikánsan ritkábbak voltak a korai szövődmények, dohányzás mellett közel kétszeres, hyperlipidaemia mellett viszont kétharmadnyi volt a sztentgraftspecifikus szövődmények esélye. Következtetés: A vizsgálati periódusban klinikánkon infrarenalis elektív sztentgraftbeültetéseknél rövidült a hospitalizációs idő, egyre kevesebb beteg került intenzív osztályos posztoperatív megfigyelésre, míg kapcsolatot találtunk a dohányzás, a diabetes és a hyperlipidaemia jelenléte, valamint a szövődmények megjelenési esélye között. Fontos kiemelni azonban, hogy az endovascularis eszközök rapid fejlődése és az alacsony esetszám miatt a speciális szövődmények hatékony követési és kezelési stratégiájának meghatározása sokszor individuális döntést igényel. Orv Hetil. 2023; 164(50): 1993–2000.

Iliac tortuosity increases reinterventions but not adverse outcomes following repair of juxtarenal aneurysms using physician-modified endografts

ObjectiveIncreased angulation of the proximal aortic neck has been associated with complications following endovascular repair of infrarenal aortic aneurysms, including increased incidence of endoleaks, stent migration, secondary interventions, and conversions. However, knowledge on the impact of aortoiliac tortuosity on outcomes following fenestrated repair remains limited. This study aims to quantify the effect of aortoiliac tortuosity on outcomes following fenestrated repair. MethodsA single-center, retrospective review of all patients who underwent a physician-modified endovascular repair for the treatment of juxtarenal aortic aneurysms under a single physician-sponsored investigation device exemption study from 2011 to 2021 was performed. Center luminal lines and geometric distances were obtained using TeraRecon software (San Mateo, CA). A tortuosity index was calculated (tortuosity index = centerline distance/geometric line distance) for each iliac vessel as well as for the infrarenal aorta according to Society for Vascular Surgery reporting standards. Aortic and iliac tortuosity were assessed independently and stratified as low and high. Demographics, comorbidities, anatomic and operative details, and outcomes were compared using univariable and multivariable analysis. ResultsA total of 135 patients were identified. Thirty-eight patients (28%) had high aortic tortuosity, and 55 patients (42%) had high iliac tortuosity. Patients with high tortuosity were older (aortic: 78 vs 76 years; P = .04; iliac: 78 vs 75 years; P = .01) and differed by sex. Twenty-two percent of men and 50% of women had high aortic tortuosity (P = .01). Forty-seven percent of men and 20% of women had high iliac tortuosity (P = .01). There were no differences in comorbidities based on aortic tortuosity, but coronary artery disease (high: 58% vs low: 36%; P = .01) and hypertension (high: 69% vs low: 86%; P = .02) differed based on iliac tortuosity. Aneurysm diameter was larger for patients with high iliac tortuosity (72 mm vs 64 mm; P < .01), and fluoroscopy time was longer for patients with high aortic tortuosity (41 vs 31 minutes; P = .02). When outcomes were assessed, high iliac tortuosity was associated with increased rate of reinterventions (hazard ratio, 2.6; 95% confidence interval, 1.2-6.0) and type 1 or 3 endoleak (hazard ratio, 5.2; 95% confidence interval, 1.7-16); however, all other outcomes were similar. ConclusionsAmong patients treated with physician-modified endovascular repair for juxtarenal aneurysms, iliac tortuosity but not aortic tortuosity, is associated with increased reinterventions and type 1 or type 3 endoleaks. Long-term follow-up is critical for patients with high iliac tortuosity to ensure that high-risk endoleaks are identified and treated early to avoid the risk of rupture.

A Single-Institution Case Series of Total Endovascular Relining for Type 3 Endoleaks in Traditional Endovascular Aneurysm Repair (EVAR) Grafts with Raised Bifurcations

The endovascular repair of infrarenal abdominal aortic aneurysms can be performed with a wide variety of devices. Many of these grafts elevate the aortic bifurcation which can limit future repairs if the graft material fails thereby creating a type III endoleak to aorto-uniliac grafts. Many manufacturers have grafts susceptible to this, but we have seen this in the Medtronic AneuRx graft. Our goal is to provide technical details and outcomes regarding a novel technique to reline these grafts while maintaining inline flow to the iliac arteries. This was a single-institution review of patients who had endoleaks requiring intervention after a previously placed graft with an elevated aortic bifurcation. Primary outcomes included technical success defined as placement of all planned devices, resolution of type III endoleak, aneurysm size at follow-up, and requirement of reintervention. Secondary outcomes included 30-day complications, aneurysm-related mortality, and all-cause mortality. Technical details of the operation include back-table deployment of an Ovation device, modification of the deployment system tether and pre-emptive placement of an up and over 0.014″ wire. The wire is placed up and over and hung outside the contralateral gate. Once the main body is introduced above the old graft, the 0.014" is snared from the contralateral side and externalized. The main body is then able to be seated at the bifurcation as the limb is not fully deployed and then device deployment is completed per instructions for use. Our study consists of 4 individuals, 3 of which had an abdominal aortic aneurysm initially managed with an AneuRx endovascular aneurysm repair and 1 with a combination of Gore and Cook grafts. All 4 patients were male with an average age of 84.5years at time of reline. All patients had at least 10years between initial surgery and reline at our institution. Primary outcomes revealed no type 1 or 3 endoleaks at follow-up, technical success was 100% and 1 patient required reintervention for aneurysm growth and type 2 endoleak. In terms of our secondary outcomes, there was 1 postoperative complication which was cardiac dysfunction secondary to demand ischemia, aneurysm-related mortality was 0% and all-cause mortality was 25% at average follow-up of 2.44years. As individuals continue to age, there are more patients who would benefit from less invasive reinterventions following endovascular aneurysm repair. Whether this is due to aortic degeneration, stent migration, or stent material damage is not always known. In this study, we present an endovascular approach to treating type III endoleak patients with a previous graft and elevated aortic bifurcation using Ovation stent grafts and found no evidence of type 1 or 3 endoleaks on follow-up imaging. This approach may allow patients with type III endoleak the option of a minimally invasive, percutaneous approach where they previously would not have had one.

Cardiac risk after elective endovascular repair for infrarenal abdominal aortic aneurysm: Results from the Italian Collaborators for EVAR multicenter registry

ObjectiveMajor adverse cardiac events (MACEs) were common complications after endovascular aortic repair (EVAR) causing significant postoperative morbidity and mortality. The aim of the study was to evaluate the cardiac risk after elective EVAR for uncomplicated noninfected infrarenal abdominal aortic aneurysm in a large multicenter cohort. MethodsThis is a multicenter, retrospective, financially unsupported physician-initiated observational cohort study conducted by four academic tertiary referral hospitals from January 2018 to March 2021. Baseline, perioperative, and postoperative information of elective EVARs was evaluated. The primary outcome was the incidence of MACEs after EVAR, which was defined as acute coronary syndrome, non-ST-elevation myocardial infarction, unstable angina pectoris, de novo atrial fibrillation, hospitalization for heart failure, and revascularization as well as cardiovascular death. Secondary outcomes were 1-year overall survival (all-cause mortality) and freedom from aorta-related mortality. Comparative analysis was conducted between MACE and overall population, and univariate and multivariate logistic regression analyses were used to analyze factors associated with the risk of the MACE occurrence and early 1-year mortality. ResultsThe study has enrolled 497 patients (35 females, 7%) with a mean age of 75.3 ± 7.8 years. The MACE rate was 6.4% (32/497, events/patients), and the majority of the events were recorded in the postoperative period (24/32, 75%; overall 24/497, 4.8%). One-year survival from all-cause mortality was 94% (95% confidence interval [CI]: 91-96), and the MACE population showed a significantly lower survival estimation rate (Overall - MACEs, 95.8% [95% CI: 93-97] - 67.9% [95% CI: 47-82], log-rank 41.950, P = .0001). Freedom from aorta-related mortality was 99.3% (95% CI: 98-100). The perioperative need for red blood cell transfusions was strongly related to the MACE occurrence (odds ratio: 2.67, 95% CI: 1.52-4.68, P = .001) and 1-year mortality (hazard ratio: 2.14, 95% CI: 1.48-3.09, P = .0001). ConclusionsMACEs represent a common complication in the postoperative and early period after elective EVAR. Blood loss requiring red blood cell transfusions is associated with increased postoperative MACEs and early mortality, suggesting that all the efforts should be carried out to reduce the bleeding during and after elective interventions.

Combined Endovascular Treatment of Complex Aortic Pathologies.

Multisegmented aortic pathologies present challenging issues independent of the treatment chosen. Whether open or endovascular, staged, or simultaneous, every treatment modality has its own pros and cons. We revealed our patients retrospectively with early and midterm results who had simultaneous endovascular thoracic and abdominal aortic repair for thoracic aortic pathologies and infrarenal abdominal aortic aneurysm (iAAA) as a single-center experience. Between January 2016 and January 2021, 16 patients were diagnosed with thoracic aortic pathology and iAAA was simultaneously repaired in an endovascular manner. All patients were operated on with the same cardiovascular surgeon team. The average age of the patients were 76.9 ± 6.2 (64-86) years. There was no early mortality. The technical success was 100%. In total, 18 thoracic endografts were deployed in 16 patients for thoracic aortic pathologies. Follow-up period was 21.85 ± 8.96 months, and in the follow-up period, two patients had a secondary intervention. One cardiac and one coronavirus disease 2019 mortality was detected in the follow-up period. There was no aneurysm-related mortality. The postoperative first-year survival was 84.6 ± 10.0. Simultaneous endovascular solution for complex multisegmented aortic pathologies provides a rapid, less-invasive approach with successful early and midterm morbidity, mortality with short intensive care unit period, and length of hospital stay. A combination of endovascular aortic aneurysm repair and thoracic endovascular aortic repair where anatomic suitability exists is a strong alternative over staged and hybrid therapies. Contrast-induced nephropathy, postimplantation syndrome, and spinal cord ischemia should be carefully monitored with this strategy.

Outcome of different endovascular modalities to treat common iliac artery aneurysms, single center study.

Iliac aneurysms occur in 10% of patients with abdominal aortic aneurysms (AAA). There are three different endovascular approaches to their treatment in the context of infrarenal Endovascular Aortic Aneurysm Repair (EVAR): occlusion by coiling the internal iliac, incorporation using an iliac branch device, and delaying repair using a bell bottom limb. We sought to determine outcomes associated with these three strategies in our practice. The study was a combined prospective cohort study with a retrospective arm: prospective patient recruitment was done for 1year from September 2019 and ended by September 2020, and retrospective data was collected from 2017 to 2019. Demographic, procedural, and imaging data was collected. SPSS was used to analyze data as patients were classified by limbs in four groups: iliac branched, bell bottom, coil and cover technique, and standard treated limbs. There were 65 male and 4 female patients included in this study incorporating 137 limbs with a mean age of 78years (SD ± 8years). Two patients died after discharge (at 3 and 21months postoperatively, without hospital admission) and five patients were lost to long-term follow-up. Three patients had operations that deviated from the plan: one was an IBD converted to bell bottom, one was an IBD that was converted to coil and cover, and one was a bell bottom that did not seal. Follow-up revealed late type IB endoleak in three bell bottom limbs and one limb treated with coil and cover. Common iliac occlusion occurred in one IBD, three bell bottom limbs, and two limbs treated with coil/cover technique. There were four additional ischemic events (buttock claudication in three and intestinal ischemia in one): all ischemic events occurred in the coil and cover group (p = .001). Given the small population size examined in this study, there is no statistical difference between treatment groups; however, there was a trend toward bell bottom technique being associated with higher incidence of type IB endoleak. Coil and cover technique was associated with decreased IB endoleak; however, Buttock claudication and intestinal ischemia occurred more significantly in this group. Using IBD may be the best strategy to improve short- and long-term outcomes in patients with iliac aneurysms.

Preliminary findings of selective endovascular repair for infra-renal abdominal aortic aneurysm at Viet Duc University Hospital

Objectives: To evaluate the early result of EVAR in abdominal aorta aneurysm patients in Viet Duc university hospital from 01/01/2018 to 30/12/2021.&#x0D; Methods: Descriptive and retrospective study with convenience sampling. Data was extracted from patient records.&#x0D; Results: There were 37 patients (30 males and 7 females), the majority of which have hypertension and DeBakey sign. Average age was 72,96 ± 6,58 (61-86) years. The fusiform aortic aneurysm was presented in all patien1,2. The average diameter, neck diameter, and aneurysm neck angle are 52.57mm, 21.26mm, and 47.02°, respectively. Moreover, 97.3% of patients were given bifurcated stent grafts; internal iliac artery was occluded in 5(13.5%) patients; The early results of the study group included the following: hospital mortality was 2,7% (1); in complications: immediately endoleak was 8(21,6%); after 30 days was 3(8,1%); acute renal failure was in 1(2,7%); hematoma in goiter was in 1(2,7%). Hospital stay was 10±4 days.&#x0D; Conclusion: The EVAR at Viet Duc University Hospital for selective abdominal aortic aneurysm is safe, effective with low risk of complication and mortality.

Value of contrast-enhanced ultrasonography in detection of endoleak after endovascular repair of infrarenal abdominal aortic aneurysm

Objective: To investigate the value of contrast-enhanced ultrasound in detecting endoleak after endovascular repair of infrarenal abdominal aortic aneurysm (EVAR). Methods: The postoperative follow-up data of 102 patients with infrarenal abdominal aortic aneurysm treated with EVAR in Tianjin Medical University General Hospital from August 2015 to December 2021 were retrospectively analyzed. There were 79 males and 23 females, aged 50-91 (69.6±7.6) years old. Using CT angiography (CTA) as the gold standard for diagnosing endoleaks, the effectiveness of contrast-enhanced ultrasound and CDUS in detecting endoleaks was evaluated by paired design chi-square test, and the Kappa value was calculated for consistency test. Patients were divided into groups according to body mass index (BMI), and the number of false-negative endoleaks detected by contrast-enhanced ultrasound in each group was calculated, and its ratio to the actual number of endoleaks was calculated to evaluate whether BMI was related to false-negative ultrasound-enhanced ultrasound. Results: A total of 203 follow-up visits met the inclusion criteria. Endoleaks were detected 36 times (17.7%) by CTA, 31 times (15.3%) by contrast-enhanced ultrasound, 16 times (7.9%) by CDUS, and they all detected type Ⅰ, type Ⅱ and type Ⅲ endoleaks. There was no significant difference between contrast-enhanced ultrasound and CTA in endoleak detection rate and determination of endoleak types (endoleak detection rate: 15.3% vs 17.7%; determination of endoleak types: type Ⅰ 4 vs 4, type Ⅱ 26 vs 31, type Ⅲ 1 vs 1; all P>0.05). CDUS and CTA had statistically significant differences in the detection rate of endoleaks and determination of endoleak types (endoleak detection rate: 7.9% vs 17.7%; determination of endoleak types: type Ⅰ 4 vs 4, type Ⅱ 11 vs 31, type Ⅲ 1 vs 1; all P<0.001). Compared with CTA, contrast-enhanced ultrasound has a sensitivity of 83.3%, a specificity of 99.4%, a Youden index of 0.827, a coincidence rate of 96.6%, a positive predictive value of 96.8%, a negative predictive value of 96.5%, and a Kappa value of 0.875(P<0.001). The two showed excellent diagnostic consistency. All 6 endoleaks not detected by contrast-enhanced ultrasound were type Ⅱ endoleak that did not require treatment, and 3(15.8%) occurred in obese patients with a BMI≥32 kg/m2. Compared with CTA, CDUS had a sensitivity of 38.9%, a specificity of 98.8%, a Youden index of 0.377, a coincidence rate of 88.2%, a positive predictive value of 87.5%, a negative predictive value of 88.2%, and a Kappa value of 0.482 (P<0.001). The two showed moderate diagnostic agreement. The correlation coefficient of the maximum diameter of aneurysms measured by ultrasound and CT was r=0.873(P<0.001). Conclusions: Contrast-enhanced ultrasound is accurate in detecting endoleak after infrarenal EVAR, and its sensitivity to endoleak detection in obese patients with BMI≥32 kg/m2 will be reduced. CDUS is not suitable for detection of endoleak after infrarenal EVAR, but it can be used to monitor the change of the largest diameter of aneurysm after EVAR.

Reintervention rate after infrarenal aortic aneurysm repair is lower for open than endovascular repair with aneurysm sac shrinkage: a fifteen-year study.

The aim of this study was to report long-term results of infrarenal abdominal aortic aneurysm (AAA) in a single tertiary Hospital. One thousand seven hundred seventy-seven consecutive AAA repairs (2003-2018) were included. Primary outcomes were all-cause mortality, AAA-related mortality, reinterventions rate. Open repair (OSR) was offered in case the patient had a functional capacity ≥4 metabolic equivalents (MET), and a predicted >10 year life expectancy. Endovascular repair (EVAR) was offered in case of hostile abdomen, presence of anatomic feasibility for standard endovascular graft, and <4 MET. Sac shrinkage was defined as a reduction of both anterior-posterior and latero-lateral diameter of the sac of at least 5 mm at the last follow-up vs. the first post- operative follow-up imaging. Eight hundred twenty-eight (47%) OSRs and 949 (53%) EVARs were performed 90.6% (N.=1610) were male, mean age was 73.8 years. Mean follow-up was 79 (SD: 51) months. 30-day mortality was 0.7% (N.=6) and 0.6% (N.=6) for OSR and EVAR respectively (P=1). Long-term survival was better for OSR as expected by the selection criteria used (P<0.001), while AAA-related death was similar in the OSR vs. EVAR group (P=0.37); 664 (70%) sac shrinkages occurred at the last follow-up in the EVAR group. Freedom from reintervention was 97% and 96% at 1 year, 96.5% and 88.4% at 5 years, 95.8% vs. 81.7% at 10 years, and 94.6% vs.72.3% at 15 years for OSR and EVAR, respectively (P<0.001). The reintervention rate was significantly lower in the sac shrinkage vs. no-sac shrinkage subgroup and but higher than the OSR (P≤0.001). Any statistical difference was found for the survival outcome in case of sac shrinkage (P=0.1). Open repair of an infrarenal AAA had a lower reintervention rate than EVAR even in case of a shrinked sac at a long-term follow-up. Further studies with greater sample size are needed.