Infrarenal Aortic Aneurysm Repair Research Articles

De novo acute type B aortic dissection in two patients with previous infrarenal endovascular aortic aneurysm repair with EndoAnchors

<h2>Abstract</h2> Acute aortic dissections in the immediate postoperative period following endovascular abdominal aortic aneurysm repair (EVAR) have been linked to technical factors such as excessive endograft oversizing or aortic wall injuries during the procedure, whereas dissections that occur later are more likely to be de novo. Regardless of their etiology, aortic dissections can extend in the abdominal aorta, causing collapsing and occlusion of the endograft with devastating complications. There have been no reports of aortic dissections in EVAR patients in whom endoanchors were used. We present two cases of de novo type B aortic dissection (TBAD) after EVAR with entry tears in the descending thoracic aorta. Interestingly in both of our cases the dissection flap appeared to stop abruptly at the site of endograft fixation with the endo-anchors, suggesting that end-anchors might prevent propagation of aortic dissections beyond the endoanchor fixation level and thus protect the EVAR from collapsing.

Incidence, reintervention, and survival associated with type II endoleak at hospital discharge after elective endovascular aneurysm repair in the Vascular Quality Initiative

BackgroundThe longitudinal clinical significance of type II endoleaks (T2ELs) remains controversial. Specifically, the real-world incidence, need for reintervention, and associated mortality referable to T2ELs remain unknown. Moreover, current professional society clinical practice guidelines recommend differing aneurysm sac growth thresholds to prompt intervention. Therefore, the purpose of this analysis was to better quantify the prevalence of early T2ELs after infrarenal endovascular aortic aneurysm repair (EVAR) and determine its association with reintervention and survival. MethodsAll elective EVARs from the Vascular Quality Initiative (2010-2020) were examined to identify patients with isolated T2ELs vs no endoleak (NONE) at discharge. Procedures with a type I or III endoleak were excluded. A subgroup analysis was performed on patients surviving beyond the first postoperative year with follow-up data available on endoleaks. The primary outcome was overall survival. Secondary outcomes included perioperative mortality and reinterventions. Outcomes were assessed by multivariable logistic and Cox proportional hazards regression to adjust for covariates. ResultsWe identified 53,697 patients who underwent EVAR. The overall incidence of isolated T2ELs at discharge was 16%. In-hospital mortality was lower for those with isolated T2ELs vs NONE (0.8% vs 1.9%, odds ratio: 0.6, 95% confidence interval: 0.5-0.8, P < .0001). Unadjusted overall survival was marginally higher at 5 years for patients with T2ELs vs NONE (84% vs 82%); however, after risk adjustment, survival was similar (hazard ratio: 0.95, 95% confidence interval: 0.9-1.0). Among 44,345 patients with 1-year follow-up, 66% had data on endoleak status for assessment. Survival was similar regardless of endoleak status (NONE, at discharge only, at follow-up only, or at both time points). Among patients with documented T2ELs during follow-up, 6.1% and 2.5% had abdominal aortic aneurysm sac diameter growth ≥5 mm and ≥10 mm, respectively. Reinterventions occurred in 12%. Rupture (1%) and any open reintervention (4%) were rare among patients with 1-year follow-up. For patients with T2ELs, 5-year survival was similar between those with and without reintervention by 1 year (89% vs 91%, log-rank P = .06). ConclusionsT2ELs remain common after EVAR within the Vascular Quality Initiative and are not associated with long-term mortality. Reinterventions for T2ELs were not associated with improved overall survival among patients with T2ELs. Although additional data surrounding the appropriate role of reintervention for T2ELs remain necessary, it appears that the natural history of T2ELs is benign.

Results of the Italian Collaborators for EVAR (ICE) Registry on Acute Kidney Injury After Elective Endovascular Aortic Repair of Infrarenal Abdominal Aortic Aneurysm

The aim of this study was 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 noninfected 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. AKI severity stage was classified according to the Acute Kidney Injury Network (AKIN) criteria. Primary outcomes were AKI incidence at 30 days and freedom from HD at 1 year of follow-up. Secondary outcomes were freedom from severe postoperative complication, and freedom from aorta-related mortality (ARM) at 1 year. We analyzed 526 patients (86.5%). There were 489 males (93%) and 37 females (7%): the median age was 76 years (interquartile range, 3-8 years). AKI was observed in 17 patients (3.2%): it was classified as AKIN stage 1 in 12 (2.3%), AKIN stage 2 in three (0.6%), and AKIN stage 3 in two (0.2%). Renal replacement therapy was needed in four (0.8%): HD in three (0.6%, transitory in 2), and continuous veno-venous hemofiltration in one (0.2%). Binary logistic regression analysis identified chronic kidney disease (odds ratio [OR] 4.68; 95% confidence interval [CI], 2.10-10.45; P < .001), and the presence of renal artery stenosis (OR, 3.80; 95% CI, 1.35-10.66; P = .011) to be associated with an increased risk of postoperative AKI. Freedom from ARM was 99.2% at 1 year. Both serum creatinine and estimated glomular filtration rate were significantly different in comparison with preoperative and postoperative level. Of the patients who developed AKI postoperatively, 15 (88.2%) did not require further renal replacement therapy at 1 year; only two patients (0.4%), who already required HD postoperatively, remained on renal replacement therapy by HD at 1 year. Mortality at 1 year was higher in patients who developed postoperative AKI (18.7% vs. 5%; OR, 5.63; P = .051). AKI after elective standard EVAR still occurs but with an acceptably low incidence rate. Preoperative chronic kidney disease is the most important predictor for postoperative AKI, which was not associated with the need of HD at 1-year follow-up but with a higher propensity of mortality.

Early Results of Elective Endovascular Repair of Infrarenal Abdominal Aortic Aneurysms With the MinosTM Stent-Graft System.

A variety of last-generation endografts are currently available for standard endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs). The purpose of this study is to report the preliminary clinical outcomes of the Minos trimodular stent-graft system, which was recently introduced to the European market. Between February 2020 and 2022, we treated 41 consecutive AAA patients (mean age 72.2±8.5, 37 males) with elective standard EVAR using the Minos. The mean maximum diameter of AAAs was 54.7±6.6 mm, the mean proximal neck's (PN) diameter was 24.8±2.7 mm, while the relevant length and angulation were 16.0 mm and 21.7°, respectively. Overall, 22 (53.6%) patients presented with shorter and angulated PN, according to the stent-graft's instructions of use, and in 6 (14.6%) patients the PN angulation >60° was combined with concomitant iliac angulation >60°. Eleven (26.8%) EVARs were performed with concomitant enormous iliac artery narrowing and tortuosity. Finally, in 19 (46.3%) AAAs, the distal iliac landing zone was aneurysmatic and they were treated with the bell-bottom technique in 17 patients and with limb extension to the external iliac artery in two cases. We evaluated technical and clinical success of the index procedures, which was based on the combination of five factors: freedom from EVAR-related mortality, from graft-related endoleak of any type, from migration at any part of graft as well the absence of notable increase AAA's sac maximum diameter and the patency of bifurcated stent-graft and of access vessels. Primary technical and clinical success of index procedures was 100%. During a median 12-month radiological follow-up the clinical success remained 100%. No type I or III endoleak, stent-graft migration, EVAR-related death, AAA rupture, or graft-related adverse events or reinterventions were documented. Four (9.8%) type II endoleaks were detected with stable AAA sac diameter. The overall incidence of sac regression was 34.1% (n=14). The preliminary results of our series showed that Minos provided excellent feasibility and safety features even through angulated and tortuous iliac vessels and in short and angulated PNs. The overall clinical success at 1 year suggests that performance of Minos follows very high standards. Further validation of these promising results with long-term data is acquired to complete the evaluation of this recently introduced stent-graft system. The current study explored the clinical performance of a new in market ultra-low profile bifurcated abdominal aortic stent-graft, the MINOS. The early and 12-month results of study suggest that implantation of this stent-graft in standard EVAR, even in hostile proximal aortic neck and iliac vessels conditions, follows very high clinical standards and encourage the further clinical use of MINOS.

O029 Adverse renal outcomes following endovascular or open repair of infra-renal and supra-renal abdominal aortic aneurysms: a systematic review and meta-analysis

Abstract Introduction This study aims to quantify the risk of permanent renal dialysis for AAA repair, with comparison between endovascular (EVAR) and open repair (OAR) techniques for suprarenal (SR) and infrarenal (IR) AAA. Methods Systematic review, meta-analysis and meta-regression of post-operative, permanent dialysis outcomes were performed, following PRISMA guidance (Prospero registration: CRD42021272422). Database searches were conducted on MEDLINE, Embase, CENTRAL using ProQuest Dialog. We included data published after 2011, reporting primary elective AAA repair, for a minimum of 100 patients with &amp;gt;75% of operations undertaken after January 1, 2000. Results Seventy-nine studies (IR AAAs: 54877 EVAR &amp; 7145; SR AAAs: 4241 EVAR &amp; 1723 OAR) were included (n=67986). Overall, low rates of permanent dialysis were reported: 0.35% of IR-EVAR, 0.68% IR-OAR, 0.82% SR-EVAR, and 0.59% SR-OAR. No significant difference in the risk of permanent dialysis for endovascular and open repair was observed (EVAR vs. OAR: odds ratio (OR) 0.52 95% CI[.06, 4.78], for IR, 2.14 [.46, 10.05], for SR). A lower risk of permanent dialysis was observed for IR vs. SR EVAR (OR .05 [0, .46]). Meta-regression indicated that post-operative permanent dialysis decreased over time as determined by study midpoint for IR-EVAR and IR-OAR. For IR-OAR, increased dialysis rates were significantly associated with study participants’ ages. Conclusion The rate of permanent dialysis &amp;lt;1% for all modalities of SR and IR AAA repair. For EVAR, the risk of dialysis was higher for SR compared to IR AAA. The likelihood of permanent dialysis has decreased with modern practice yet increases among older patients.

Why Do Women Stay Longer in Hospital After Elective Endovascular Repair for Infrarenal Aortic Abdominal Aortic Aneurysms? A Nationwide Investigation from the United Kingdom

Why Do Women Stay Longer in Hospital After Elective Endovascular Repair for Infrarenal Aortic Abdominal Aortic Aneurysms? A Nationwide Investigation from the United Kingdom

Risk factors of type 1A endoleak following endovascular aortic aneurysm repair.

Endovascular repair of infrarenal aortic aneurysms are the treatment of first choice. However, the proximal sealing of endovascular aneurysm repair is the Achilles' heel of the procedure. Insufficient proximal sealing can lead to endoleak type 1A and therefore expansion of the aneurysm sack and subsequent rupture. We performed a retrospective analysis of all consecutive patients with an infrarenal abdominal aneurysm treated with endovascular aneurysm repair. We studied whether demographic and anatomical features were risk factors for endoleak type 1A. Also, the results of different treatment strategies were described. 257 Patients were included in the study, most patients were male. In the multivariate analysis, female gender and infrarenal angulation were the most important risk factors for endoleak type 1A. Endoleak type 1A diagnosed at completion angiography disappeared in 77.8%. The occurrence of endoleak type 1A was associated with a higher risk of aneurysm-related mortality (p = 0.01). Conclusions should be drawn with care, since the number of patients included in this study was small and there was a high incidence of patients lost to follow-up. This study suggests that endovascular aneurysm repair in female patients and patients with severe infrarenal angulation is associated with a higher risk of endoleak type 1A.

Morphological and Clinical Predictors of Early/Follow-up Failure of the Endovascular Infrarenal Abdominal Aneurysm Repair With Currently Available Endografts

Purpose: To report outcomes of endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs) with currently-available endografts and identify predictors of technical/clinical failure. Materials and Methods: Patients undergoing EVAR between 2012 and 2020 were prospectively collected and retrospectively analyzed. Technical success (TS: no type I–III endoleaks, renal/hypogastric arteries loss, iliac leg occlusion, conversion to open repair and mortality within 24 postoperative hour), proximal neck–related TS (nr-TS: no proximal type I endoleaks, unplanned renal arteries coverage), and 30-day mortality were assessed as early outcomes. Proximal type I endoleak (ELIa), survival and freedom from reinterventions (FFRs) were assessed during follow-up. Uni/multivariate analysis and Cox-regression were used to identified factors associated with early and follow-up outcomes; FFR and survival were assessed by Kaplan-Meier analysis. Results: A total of 710 were included. Technical success and nr-TS were 692 (98%) and 700 (99%), respectively. The presence of ≥2 hostile anatomical infrarenal neck characteristics was associated with technical failure (odds ratio [OR]: 2.4; 95% confidence interval [CI]: 1.3–4.1; p: 0.007). Infrarenal neck angle >90° (OR: 2.88; 95% CI: 9.6–50.3; p: 0.004), barrel shape (OR: 2.33; 95% CI: 11.1–100.3; p: 0.02) or presence of ≥2 hostile anatomical infrarenal neck characteristics (OR: 2.16; 95% CI: 2.5–5.3; p: 0.03) were independent risk factors for neck-related technical failures. Six (0.8%) patients died within 30 postoperative days. Chronic obstructive pulmonary disease (OR: 16; 95% CI: 1.1–218.3; p: 0.04) and urgent repair (OR: 15; 95% CI: 1.8–119.6; p: 0.01) were independent risk factors for 30-day mortality. The mean follow-up was 53±13 months. There were 12 (1.7%) ELIa during follow-up. Infrarenal neck length <15 mm (hazard ratio [HR]: 2.8; 95% CI: 1.9–9.6; p: 0.005), diameter >28 mm (HR: 2.7; 95% CI: 1.6–9.5; p: 0.006), angle ≥90° (HR: 2.7; 95% CI: 8.3–50.1; p: 0.007), and persistent type II endoleak (HR: 2.9; 95% CI: 1.6–10.1; p: 0.004) were independent risk factors for ELIa. Freedom from reintervention was 91% at 5 years. The ELIa was an independent risk factor for reinterventions during follow-up (HR: 29.5; 95% CI: 1.4–1.6; p<0.001). Survival was 74% at 5 years with 2 cases (0.3%) of late aortic-related mortality. Peripheral arterial occlusive disease (HR: 1.9; 95% CI: 1.4–3.65; p: 0.03), aneurysm diameter ≥65 mm (HR: 2.2; 95% CI: 1.4–3.26; p<0.001), and infrarenal neck length <15 mm (HR: 1.7; 95% CI: 1.2–2.35; p: 0.04) were independent risk factors for mortality during follow-up. Conclusion: Endovascular repair with currently-available endografts has high TS and low 30-day mortality. Survival and FFRs were satisfactory at mid-term. Pre/postoperative risk factors for technical and clinical failure were identified and they should be considered in EVAR indication and postoperative management to reduce complications and improve mid-term outcome. Clinical Impact Pre and postoperative risk factors for technical and clinical EVAR failure can be identified and they should be considered in EVAR indication and postoperative management to reduce complications and improve mid-term outcome.

Technological Advances to Address the Challenging Abdominal Aortic Aneurysm Neck.

There have been significant technologic advances in endovascular aortic therapies since the introduction of conventional infrarenal endovascular aortic aneurysm repair (EVAR). These advances have sought to address the weaknesses of conventional EVAR- particularly the difficult or "hostile" infrarenal aortic aneurysm neck. We review anatomical features that create a hostile neck and the most recent advancements to overcome these limitations. EndoAnchors replicate open suture fixation to seal endograft to aortic tissue and have been shown to be useful as a prophylactic measure in short, angulated necks as well as therapeutic for type Ia endoleaks. Fenestrated EVAR (FEVAR) devices such as the Z-fen (Cook Medical, Bloomington, IN, USA) raises the seal zone to the suprarenal segment while maintaining renal perfusion. Finally, multibranch aortic grafts such as the Thoracoabdominal Branch Endoprosthesis (Tambe; W. L. Gore & Associates, Flagstaff, AZ, USA) raise the seal zone above the visceral segment and can be used off the shelf with promising results.

Early results of open surgical repair of infrarenal abdominal aortic aneurysms with silver coated grafts at Thai Binh Provincial General Hospital

Objective&#x0D; Open surgical abdominal aortic repair, involving the excision of dilated area and placement of a synthetic graft is a common, major operation done to treat an aortic aneurysm. This procedure, however, is a challenge for cardiovascular surgeons because of its postoperative mortality and complications. The objective of this research is to study the prognostic factors and early results of open surgical repair (OSR) for abdominal aortic aneurysms (AAA), beginning below the renal arteries.&#x0D; Methods&#x0D; This is a descriptive retrospective study on patients with infrarenal AAA, who underwent OSR to replace the aneurysmal sac with a silver coated synthetic graft at Thai Binh Provincial General Hospital from June 2019 to June 2021&#x0D; Results&#x0D; 40 cases including 28 males and 12 females were eligible for our study. The average age of the studied groups was 68.7 ± 8.95 years old. Common observed clinical symptoms of this demographic included hypertension, lipid metabolism disorders. Most of the aneurysm sacs were rhomboid-shaped with the diameter and the neck length ranged of 5-8 cm and 1.8 ± 0.75cm respectively. The success rate of the procedure was 100%. Pneumonia was the most commonly seen postoperative complication. There was no complication related to the grafts. 02 deaths were reported after surgery due to multi-organ failure. GA (Glasgow Aneurysm) score was excellent and the Hardman score was a good predictor of mortality.&#x0D; Conclusions: &#x0D; OSR was a common treatment method for ruptured AAA and AAA that can not be indicated with endovascular placement of an aortic stent graft (EVAR). It was crucial to take prognostic factors into consideration so as to avoid postoperative complications.

Major adverse cardiac events after elective infrarenal endovascular aortic aneurysm repair.

There is a significant cardiac morbidity and mortality after endovascular aneurysm repair (EVAR). However, information about long-term risk of cardiac events after EVAR and potential predictors is lacking. Therefore, the aim of this study was to determine incidence and predictors of major adverse cardiac events (MACE) at 1 and 5years after elective EVAR for infrarenal abdominal aortic aneurysms. Baseline, perioperative, and postoperative information of 320 patients was evaluated. The primary outcome was the incidence of MACE after EVAR, which was defined as acute coronary syndrome, unstable angina pectoris, de novo atrial fibrillation, hospitalization for heart failure, mitral valve insufficiency, revascularization (including percutaneous coronary intervention and coronary artery bypass grafting), as well as cardiovascular and noncardiovascular death. Kaplan-Meier analyses were performed to determine incidences of MACE, MACE excluding noncardiovascular death and cardiac events by excluding noncardiovascular and vascular death from MACE. Predictors of MACE were identified using univariate and multivariate binary regression analysis. Through 1 and 5years of follow-up after EVAR, freedom from MACE was 89.4% (standard error [SE], 0.018) and 59.8% (SE, 0.033), freedom from MACE excluding noncardiovascular death was 94.7% (SE, 0.013) and 77.5% (SE, 0.030) and freedom from cardiac events was 96.0% (SE, 0.011) and 79.1% (SE, 0.030), respectively. Predictors for MACE within 1year were American Society of Anesthesiologists (ASA) score of III or IV (odds ratio [OR], 3.17; 95% confidence interval [CI], 1.52-6.59) and larger abdominal aortic diameter (OR, 1.04; 95% CI, 1.01-1.08). A history of atrial fibrillation (OR, 0.14; 95% CI, 0.03-0.60) was a negative predictor factor. Predictors for MACE through 5years were a history of heart failure (OR, 4.10; 95% CI 1.36-12.32) and valvular heart disease (OR, 2.31; 95% CI, 0.97-5.51), American Society of Anesthesiologists score of 3 or 4 (OR, 1.66; 95% CI, 0.96-2.88), and older age (OR, 1.04; 95% CI, 1.01-1.08). MACE is a common complication during the first 5years after elective EVAR. Cardiac diseases at baseline are strong predictors for long-term MACE and potentially helpful in optimizing future postoperative long-term follow-up.

Major adverse cardiac events after elective infrarenal endovascular aortic aneurysm repair

Major adverse cardiac events after elective infrarenal endovascular aortic aneurysm repair

Percutaneous Approach in Endovascular Aortic Procedures Using a Suture-Mediated Closure Device.

The purpose of this study is to assess the efficacy of a suture-mediated closure device during percutaneous endovascular aortic repair. A single-center, retrospective analysis of patients undergoing endovascular repair for infrarenal, thoracic and thoracoabdominal aortic aneurysms and aortic dissections via percutaneous femoral access between April 2017 and June 2021 was performed. The primary endpoint of the study was the efficacy and technical success of the Perclose ProGlide closure device during percutaneous endovascular procedures. The secondary endpoints were intraoperative and postoperative inguinal and vascular complications during and after device use. A total of 376 punctures were performed in 263 patients with the deployment of the ProGlide vascular closure system. Twenty-two cases involved percutaneous re-puncture as part of a staged procedure. The primary and secondary technical success rates were 93.1% (350/376) and 94.7% (356/376), respectively. In 20 patients (5.3%), intraoperative femoral exposure due to complications was required. Postoperative complications occurred in 13 cases (3.5%), 2 of which required surgical reintervention. There was no statistical significance between the type of endovascular procedure and primary technical success (p = 0.56). The introduction of larger-diameter sheaths was not associated with increased intraoperative and postoperative complication rates (p = 0.75 and p = 0.78, respectively). Percutaneous re-puncture of the vascular access site did not result in a lower overall technical success rate (20/22, 90.9% primary technical success rate, p = 0.67; 21/22, 95.5% secondary technical success rate, p = 0.86) or an increased number of perioperative complications (1/22, 4.5% intraoperative complications, p = 0.86; 2/22, 9.1% postoperative complications, p = 0.13). The application of the ProGlide closure system is a safe and efficient method to achieve hemostasis during percutaneous endovascular aortic repair. Complex aortic pathologies, which often require a staged approach with re-puncture, can also be successfully treated with this closure system.

Endovascular infrarenal aortic aneurysm repair: Perhaps we've gone about it all wrong

Endovascular infrarenal aortic aneurysm repair: Perhaps we've gone about it all wrong

Impact of Hypogastric Artery Coverage Versus Preservation on Clinical Outcomes of Endovascular Repair of Infrarenal Aortic Aneurysms

During endovascular aneurysm repair (EVAR), iliac arteries are used as distal seal zones for stent grafts. Lack of adequate length in the common iliac artery necessitates landing in the external iliac artery and compromising pelvic blood flow through the internal iliac artery (IIA). Recently, the US Food and Drug Administration approved endografts as well as physician-modified endografts to preserve the blood flow of the IIA. However, evidence on the benefit of sparing pelvic blood flow is lacking.

Association Between Body Mass Index and Outcomes Following Endovascular Aneurysm Repair

This study assessed the differences in mortality and complication rates between normal weight, overweight, and obese patients undergoing endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysms (AAAs).

Predictors of Early and Late Failure After Contemporary Standard EVAR Procedures

The objective of this study was to report early/follow-up outcomes of standard endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs) with currently available endograft and identify predictors of technical/clinical failure.

An observational assessment of aortic deformation during infrarenal and complex endovascular aortic aneurysm repair

ObjectiveReal-time aortic deformation during endovascular aortic aneurysm repair (EVAR) has not been reported. Successful EVAR relies on predicting intraoperative aortic-endograft deformation from preoperative imaging. Correct prediction is essential, because malalignment of endografts decreases patient survival. We describe intraoperative aortic deformation during infrarenal EVAR and complex fenestrated/branched EVAR (F/BEVAR), relating deformation to preoperative anatomy and follow-up outcomes. MethodsA multicenter, retrospective cohort of aortic aneurysm patients undergoing operation between January 2019 and February 2021, substratified by repair, infrarenal EVAR (n = 50), F/BEVAR (n = 80), and iliac branch graft with F/B/EVAR (IBG + F/B/EVAR; n = 27), were compared using software-based nonrigid two- and three-dimensional aortic deformational intraoperative assessment (CYDAR). Preoperative computed tomography reconstructions of aortic and iliac tortuosities were assessed against intraoperative deformation, the primary outcome, and related to perioperative and follow-up adverse outcomes. ResultsAll treatment groups had low preoperative visceral aortic tortuosity; the EVAR group had higher iliac tortuosity (1.43 ± 0.05; P = .018). Intraoperative aortic visceral deformation was consistently cranial and anterior; IBG + F/B/EVAR patients had the largest magnitude deformation (superior mesenteric artery, EVAR 5.1 ± 0.9 mm; F/BEVAR 4.4 ± 0.4 mm; IBG 8.3 ± 1.2 mm; P = .004). Celiac artery, superior mesenteric artery, and bilateral renal artery deformations were correlated (R = 0.923-0.983). Iliac deformation was variable in magnitude and direction. Preoperative tortuosity was not correlated with the magnitude of intraoperative deformation nor was deformation magnitude related to endograft instability during follow-up, including endoleak development, reinterventions, or visceral vessel complications. ConclusionsThe aorta deforms consistently during EVAR at the visceral aortic segment but unpredictably at the iliac bifurcation. Aortoiliac deformation is unrelated to adverse perioperative outcomes, branch instability, or reinterventions during short-term follow-up.

European Expert Opinion on Infrarenal Sealing Zone Definition and Management in Endovascular Aortic Repair Patients: A Delphi Consensus

Purpose: The purpose of the study was to provide a consensus definition of the infrarenal sealing zone and develop an algorithm to determine when and if adjunctive procedure(s) or reintervention should be considered in managing patients undergoing endovascular aortic repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA). Methods: A European Advisory Board (AB), made up of 11 vascular surgeons with expertise in EVAR for AAA, was assembled to share their opinion regarding the definition of preoperative and postoperative infrarenal sealing zone. Information on their current clinical practice and level of agreement on proposed reintervention paths was used to develop an algorithm. The process included 2 virtual meetings and 2 rounds of online surveys completed by the AB (Delphi method). Consensus was defined as reached when ≥ 8 of 11 (73%) respondents agreed or were neutral. Results: The AB reached complete consensus on definitions and measurement of the pre-EVAR target anticipated sealing zone (TASZ) and the post-EVAR real achieved sealing zone (RASZ), namely, the shortest length between the proximal and distal reference points as defined by the AB, in case of patients with challenging anatomies. Also, agreement was achieved on a list of 4 anatomic parameters and 3 prosthesis-/procedure-related parameters, considered to have the most significant impact on preoperative and postoperative sealing zones. Furthermore, the agreement was reached that in the presence of visible neck-related complications, both adjunctive procedure(s) and reintervention should be contemplated (100% consensus). In addition, adjunctive procedure(s) or reintervention can be considered in the following cases (% consensus): insufficient sealing zone on completion imaging (91%) or on the first postoperative computed tomography (CT) scan (91%), suboptimal sealing zone on completion imaging (73%) or postoperative CT scan (82%), and negative evolution of the actual sealing zone over time (91%), even in the absence of visible complications. Conclusions: AB members agreed on definitions of the pre- and post-EVAR infrarenal sealing zone, as well as factors of influence. Furthermore, a clinical decision algorithm was proposed to determine the timing and necessity of adjunctive procedure(s) and reinterventions.

Cost-effectiveness of computed tomography versus ultrasound-based surveillance following endovascular aortic repair of intact infrarenal abdominal aortic aneurysms

BackgroundWhile Society for Vascular Surgery guidelines recommend computed tomography angiography (CTA) or ultrasound for surveillance following infrarenal endovascular aortic repair (EVAR), there is a lack of consensus regarding optimal timing and modalities. We hypothesized that ultrasound-based approaches would be more cost-effective and developed a cost-effectiveness analysis to estimate the lifetime costs and outcomes of various strategies. MethodsWe developed a decision tree with nested Markov models to compare five surveillance strategies: yearly CTA, yearly CDU, yearly CEU, CTA at first year followed by CDU, and CTA at first year followed by CEU. The model accounted for differential sensitivity, specificity, and risk of acute kidney injury after CTA, and was implemented on a monthly cycle with a willingness-to-pay threshold of $50,000 per quality-adjusted life year (QALY) and 3% annual discounting. ResultsUnder base case assumptions, the CTA-CDU strategy was cost effective with a lifetime cost of $77950 for 7.74 QALYs. In sensitivity analysis, the CTA-CDU approach remained cost-effective when CEU specificity was less than 95%, and risk of acute kidney injury following CTA was less than 20%. At diagnostic sensitivities below 75% for CEU and 55% for CDU, a yearly CTA strategy maximized QALYs. ConclusionsA hybrid strategy in which CTA is performed in the first year and CDU is performed annually thereafter is the most cost-effective strategy for infrarenal EVAR surveillance in patients with less than a 20% risk of contrast-induced nephropathy. If the sensitivity of CEU and CDU are at the lower end of plausible estimates, a yearly CTA strategy is reasonable. Further research should aim to identify patients who may benefit from alternative surveillance strategies.