Infrarenal Aortic Aneurysm Research Articles

P-108 MARJOLIN'S ULCER AS A COMPLICATION OF UNRESOLVED OPEN ABDOMEN

Abstract Introduction Marjolin's ulcer (MU) is a rare cutaneous tumour, commonly associated with chronic wounds with difficult healing. We present a case of UM diagnosed on a persistent unresolved open abdominal closure wound. Materials and Methods 80-year-old male with a history of ruptured infrarenal aortic aneurysm (2010) that required aorto-unifemoral repair. Postoperative period requiring decompressive laparotomy for abdominal compartment syndrome and treated with negative pressure therapy, and impossibility of definitive abdominal closure due to abdominal muscle retraction. Loss of outpatient follow-up for 10 years. Consultation for worsening of the surgical wound with abdominal pain. Examination revealed abdominal incisional hernia M2–4W3 and large abdominal ulcer. Biopsies positive results for squamous cell carcinoma with infiltrative pattern. A computed tomography describes an abdominal wall mass of 14×6×11cm and space-occupying lesion in the left hepatic lobe. Liver biopsy showed a moderately differentiated hepatocarcinoma. Surgical management consist in intramuscular injection of botulinum toxin and en bloc resection of granulation and ulcerated tissue and ileal loop attached to the lesion. Wall reconstruction with anterior separation of components and supraponeurotic mesh. Conclusions Marjolin's ulcer is associated with squamous cell carcinoma with a high rate of metastasis and mortality. This tumour is considered infrequent, of long-term duration and associated with developing societies. In our environment, this neoplasia can develop in patients with open abdomen treated partially or with closure by second intention, so we consider it necessary to have a high index of diagnostic suspicion in these cases and to perform biopsies for its detection.

The choice of bridging stents in fenestrated endovascular aortic repair

PURPOSE: To study the medium and long-term patency and endoleak rate of visceral arteries in fenestrated endovascular aortic repair (fEVAR), and explore the strategies for bridging stent selection. METHODS: The clinical data of 44 patients with thoracoabdominal aneurysms, infrarenal short-necked aortic aneurysms and aortic dissection involving the visceral artery treated using fEVAR were reviewed. The indications for stents for different visceral vessels were evaluated. RESULTS: A total of 104 target vessels were revascularized with 7 scallops and 97 fenestrations. Among them, 12 were without stents and 92 were bridged with 96 stent-grafts, including 28 uncovered stents and 68 covered stents. The success rate of the one-time placement of bridging stents was 95.7% (88/92). The overall Type-I endoleak rate was 2.9% (3/104), and the overall visceral stent patency rate was 97.1%. The receiver operating characteristic curve revealed that the critical distances between the celiac trunk artery, superior mesenteric artery (SMA), renal artery, and aneurysm were 10.25 mm, 4.3 mm, and 10.05 mm, respectively, for selecting covered stents or uncovered stents and 12.4 mm for SMAs with or without stents. CONCLUSION: The branch-to-aneurysm distance may be important for bridging stents choice in fEVAR.

Initial experiences with percutaneous endovascular aortic reconstruction

Introduction: Percutaneous aortic reconstruction is another milestone in aortic surgery. The evolution of vascular closure devices played a key role by enabling arterial closure after large -bore endovascular devices without the need of arterial cut -down.Objective: Our objective was to determine technical success of percutaneous endovascular aortic repair and to report our initial experience using this technique in a Hungarian cohort.Method: Between 15 October 2020 and 21 March 2021, patients who underwent endovascular aortic reconstruction were prospectively and consecutively collected. Patients who were deemed suitable for common femoral artery per cutaneous access were enrolled to the study. Technical success, access -site complications and risk factors were ana- lyzed.Results: A total of 43 patients underwent endovascular aortic reconstruction during the study period, of whom 38 were deemed feasible for percutaneous repair. Dominantly infrarenal aortic aneurysms were treated (n = 26, 68.4%). After ultrasound -guided access, suture -mediated devices were used 2 (1-4) per artery (median, min-max) for clo- sure. Technical success was reported in 37 out of 38 cases (97.4%). Access site complication was reported in 3 (7.9%) cases. The mean (+/- SD) in -hospital stay was 4.9 (+/- 1.7) days. Out of the 3 cases, 1 required intraoperative femoral cut-down. Sheath-size larger than 18 Fr (1.26, 0.09-17.75, 0.862) and body mass index (1.17, 0.923-1.5, 0.19) were positively associated with access site complication but no significant correlation was reported (OR, 95% CI, p- value). However, in patients with larger than 30 kg/m2 body mass index (n = 12), access-related complication was significantly higher than in smaller patients (p = 0.008).Conclusion: Percutaneous endovascular aortic repair is a promising and safe option that has a high technical success rate in patients deemed eligible for common femoral artery access.

Identifying novel mechanisms of abdominal aortic aneurysm via unbiased proteomics and systems biology.

BackgroundAbdominal aortic aneurysm (AAA), characterized by a continued expansion of the aorta, leads to rupture if not surgically repaired. Mice aid the study of disease progression and its underlying mechanisms since sequential studies of aneurysm development are not feasible in humans. The present study used unbiased proteomics and systems biology to understand the molecular relationship between the mouse models of AAA and the human disease.Methods and resultsAortic tissues of developing and established aneurysms produced by either angiotensin II (AngII) infusion in Apoe−/− and Ldlr−/− mice or intraluminal elastase incubation in wildtype C57BL/6J mice were examined. Aortas were dissected free and separated into eight anatomical segments for proteomics in comparison to their appropriate controls. High-dimensional proteome cluster analyses identified site-specific protein signatures in the suprarenal segment for AngII-infused mice (159 for Apoe−/− and 158 for Ldlr−/−) and the infrarenal segment for elastase-incubated mice (173). Network analysis revealed a predominance of inflammatory and coagulation factors in developing aneurysms, and a predominance of fibrosis-related pathways in established aneurysms for both models. To further substantiate our discovery platform, proteomics was performed on human infrarenal aortic aneurysm tissues as well as aortic tissue collected from age-matched controls. Protein processing and inflammatory pathways, particularly neutrophil-associated inflammation, dominated the proteome of the human aneurysm abdominal tissue. Aneurysmal tissue from both mouse and human had inflammation, coagulation, and protein processing signatures, but differed in the prevalence of neutrophil-associated pathways, and erythrocyte and oxidative stress-dominated networks in the human aneurysms.ConclusionsIdentifying changes unique to each mouse model will help to contextualize model-specific findings. Focusing on shared proteins between mouse experimental models or between mouse and human tissues may help to better understand the mechanisms for AAA and establish molecular bases for novel therapies.

Fenestrated and/or branched aortic stentgrafts: effect of a high volume on the learning curve

The treatment of non infrarenal aortic aneurysms (NIAA) (juxta/pararenal and thoraco-abdominal [TAA]) with fenestrated and/or branched stentgrafts (F/B-EVAR) requires mature technical skills. The objective was to evaluate the results of the initial experiment and the learning curve of an operator trained in a high-volume aortic center.

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

Infrarenal Aortic Aneurysm Distorted by Severe Spinal Deformation

A 47 year old female with severe spinal deformation presented with chest tightness for two months. (A) Computed tomographic angiography illustrated a distorted 13 cm infrarenal aortic aneurysm compressing the left thoracic cavity. The aneurysmal neck was located at the aortic hiatus, where the superior mesenteric artery (A, asterisk) and elongated renal arteries (B, arrows) originated. Due to the anatomical characteristics, laparotomy was performed and a diaphragmatic crural incision was made to control the aneurysm neck; the aneurysm was replaced with a bifurcated prosthetic graft. The patient had an uneventful recovery.Image 1

Deep Learning–Based Intraoperative Stent Graft Segmentation on Completion Digital Subtraction Angiography During Endovascular Aneurysm Repair

Purpose: Modern endovascular hybrid operating rooms generate large amounts of medical images during a procedure, which are currently mostly assessed by eye. In this paper, we present fully automatic segmentation of the stent graft on the completion digital subtraction angiography during endovascular aneurysm repair, utilizing a deep learning network. Technique: Completion digital subtraction angiographies (cDSAs) of 47 patients treated for an infrarenal aortic aneurysm using EVAR were collected retrospectively. A two-dimensional convolutional neural network (CNN) with a U-Net architecture was trained for segmentation of the stent graft from the completion angiographies. The cross-validation resulted in an average Dice similarity score of 0.957 ± 0.041 and median of 0.968 (IQR: 0.950 – 0.976). The mean and median of the average surface distance are 1.266 ± 1.506 mm and 0.870 mm (IQR: 0.490 – 1.430), respectively. Conclusion: We developed a fully automatic stent graft segmentation method based on the completion digital subtraction angiography during EVAR, utilizing a deep learning network. This can provide the platform for the development of intraoperative analytical applications in the endovascular hybrid operating room such as stent graft deployment accuracy, endoleak visualization, and image fusion correction.

Abdominal aortic aneurysms-open vs. endovascular treatment : Decision-making from the perspective of the vascular surgeon

In the last 20years, the treatment of abdominal aortic aneurysms has essentially evolved from surgical to minimally invasive endovascular treatment. There are still anumber of clinical situations that make surgical intervention useful or even necessary. This underlines the importance of interdisciplinary vascular centers for the treatment of complex aortic pathologies and their sequelae. In the following article, the arguments for the choice of procedure for the treatment of infrarenal aortic aneurysms are discussed and the recommendations of various guidelines are compared.

Endovaskuläre Versorgung: der komplizierte Aneurysmahals

DefinitionA hostile neck is defined by various anatomical conditions that describe a morphology of the proximal aneurysmal neck of infrarenal aortic aneurysms that is unfavorable for endovascular treatment (endovascular aortic repair, EVAR): proximal landing zone length ≤ 15 mm, angulation of the aortic neck > 60°, conical aortic neck, diameter of the aortic neck > 32 mm, and circumferential calcification/thrombus.Effects on outcomeThese morphological parameters are not only associated with a higher perioperative technical failure rate (primary type 1 endoleak) but also with poorer long-term results (secondary type 1 endoleak) and thus a higher reintervention rate in standard EVAR, so that standard EVAR should be reserved for a few exceptions in these cases.Treatment optionsDue to the rapid development of endovascular techniques in the last decade, we now have a variety of endovascular options for aneurysms with hostile necks, for both elective treatment and emergency care, in addition to conventional open surgery, which is still the standard method in many cases and is currently undergoing a renaissance: fenestrated endovascular aortic repair (FEVAR) as the method of first choice in the elective setting, EVAR with chimneys (ChEVAR), endosuture aneurysm repair (ESAR). An important option is the conservative approach, which can be a reasonable choice if the patient’s preference is taken into account and a careful risk–benefit assessment is performed.

Late Outcomes of Elective Endovascular Abdominal Aortic Aneurysm Repair in a Tertiary Low-Volume Hospital in Brazil

The aim of this study is to report early and long-term results of elective endovascular aneurysm repair (EVAR) in a tertiary low-volume hospital in Brazil. Between October 2006 and May 2017, 120 patients underwent elective EVAR for infrarenal aortic aneurysm. The interventions were reviewed retrospectively, focusing on 30-day mortality, long-term survival, and freedom from reintervention. Late outcomes were assessed by the Kaplan-Meier method and Cox regression. The follow-up's median and interquartile range was 3 (1-5) years. Overall, most patients were males (75%) and the median age was 74years. Mostly patients were at a high risk for intervention (79.1%) and the majority was classified as American Society of Anesthesiologists III (53.3%). Preoperative aneurysm diameter median was 60mm, interquartile range was 52.7-69. As per the postoperative aneurysm sac evolution, the number of patients with a reduction, stabilization, or an increase was 93 (77.5%), 18 (15%), and 9 (7.5%), respectively. The 30-day mortality was 6.6% and no late aneurysm-related deaths were identified. The overall incidence of late endoleaks was 24.1%, with the predominance of type II (23.3%), followed by type IA (0.8 %). Secondary interventions were necessary for 9 patients (7.5%). The 6-year analyses revealed freedom from reintervention and overall survival of 87.9% and 57.7%, respectively. The Cox regression analyses identified age > 75years as an adverse factor for overall survival (hazard ratio=2.5; P=0.021). In the present study, EVAR in a low-volume center was associated with high 30-day mortality, but satisfactory long-term results were identified.

Endovascular Repair for Juxtarenal Aortic Aneurysm – Network Meta-Analysis Support ESVS AAA guidelines!

Surgical management of juxtarenal abdominal aortic aneurysms represent a significant challenge in contemporary vascular surgery. As in other fields of vascular surgery, this specific subset of vascular disease has experienced tremendous development over the past two decades with the advances in endovascular techniques. However, unlike infrarenal aortic aneurysms, the cohort of patients with juxtarenal aneurysms is much smaller and thus poses scientific challenges when attempting to compare various treatment techniques.

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.

Open Repair of an Infrarenal Aortic Aneurysm Is Superior to Endovascular Repair Even in Case of Sac Shrinkage at Fifteen-Year Follow-up

Open Repair of an Infrarenal Aortic Aneurysm Is Superior to Endovascular Repair Even in Case of Sac Shrinkage at Fifteen-Year Follow-up

Endovascular Treatment of Infrarenal Aortic Aneurysm With Difficult Neck Anatomy

At present, endovascular treatment of infrarenal aortic aneurysms is the standard of care. However, worse aortic aneurysm anatomy is one of the main risk factors limiting the use of endovascular treatment of abdominal aortic aneurysms and leads to endoleak type I, endograft dislocation, and an increased risk of reintervention. The aim of our study was to demonstrate our single-center experience with the Gore conformable Excluder (GCE) endograft implantation in patients with difficult abdominal aortic aneurysm neck anatomy.

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.

Features of Diagnosis and Surgical Treatment of Abdominal Aortic Aneurysms with a Horseshoe Kidney

Introduction. Reconstructive surgery of abdominal aortic aneurysms, despite significant international experience, remains one of the most complex issues of current vascular surgery, especially due to anatomical variability of arterial blood supply of the kidneys and abnormalities in their development, among which the most common is a horseshoe kidney. Features of vascularization, placement of the renal isthmus relative to the main vessels, the choice of the optimal method of abdominal aortic aneurysm reconstruction cause a high risk of surgery. The issues of open and endovascular aortic grafting, possibility of crossing the isthmus of the horseshoe kidney, feasibility of reconstruction of additional renal arteries still remain controversial.
 The aim. Improvement of the diagnosis and surgical treatment of abdominal aortic aneurysms with a horseshoe kidney.
 Case presentation. In our observation, in a 61-year-old patient, by clinical examination, laboratory and diagnostic imaging the diagnosis of two infrarenal abdominal aortic aneurysms with a horseshoe kidney was confirmed, that has become a direct indication for surgical intervention: exclusion of infrarenal aortic aneurysms from the blood flow, abdominal aortic prosthetic grafting with reimplantation of the renal isthmus arteries into the prosthetic graft. This clinical case confirms the advantages of open surgical technique, using transperitoneal approach, which not only provided sufficient exposure of the operating area, but also allowed to perform optimal reconstruction of the abdominal aorta without crossing the functioning isthmus of the horseshoe kidney with preservation of blood flow through additional renal arteries.
 Conclusion. Careful preoperative assessment of the peculiarities of the blood supply of the horseshoe kidney with coexistent abdominal aortic aneurysms allows to optimize the tactics of surgical treatment, prevent the development of severe complications and achieve complete recovery of the patient.

Factors Associated With Spontaneous Sac Shrinkage in Patients With Persistent Type 2 Endoleaks After EVAR

Purpose: Despite controversy surrounding the management of type 2 endoleaks (T2ELs) after endovascular aortic aneurysm repair (EVAR), the current European guidelines recommend reintervention for T2ELs when the aneurysm expands by ≥10 mm. Meanwhile, sac shrinkage ≥10 mm can be considered low risk for failure even with T2ELs, and the guidelines suggest less frequent follow-up delayed until 5 years after EVAR. This study reviewed patients with persistent T2ELs to identify predictors of spontaneous sac shrinkage (SpS) within 5 years. Methods: A retrospective review of elective EVAR for infrarenal aortic aneurysms between June 2007 and December 2017. Patients with >1 year follow-up and persistent T2ELs, defined as T2ELs confirmed at both the 6 and 12 month follow-up with contrast-enhanced computed tomography (CT), were included. Any reintervention or type 1 or 3 endoleaks within 12 months were excluded. SpS was defined as a ≥10 mm reduction in diameter without any reintervention. Aneurysm enlargement (AnE) was defined as a ≥5 mm increase in diameter. Factors associated with SpS within 5 years were analyzed. The clinical outcomes were reviewed. Results: Among 726 patients, 162 patients had persistent isolated T2ELs. After excluding 21 patients, 141 patients were enrolled. During a median follow-up of 43 months (interquartile range [IQR], 26–60), 28 SpS and 39 AnE were observed, and 31 reinterventions were performed. The cumulative rates of SpS were 14.2%±2.9% and 25.6%±5.1% at 1 and 5 years. Cox regression analysis revealed that the presence of ≥6 patent lumbar arteries had a significant negative correlation with SpS (p=0.036). During further follow-up after SpS, 2 reinterventions for type 1a and 3b endoleaks were required at 49 and 45 months. Conclusions: Patients with fewer patent lumbar arteries were likely to experience SpS within 5 years, even in the presence of persistent T2ELs. Follow-up imaging studies were advisable earlier than 5 years, even after SpS.

Fully Ultrasound-Assisted Endovascular Aneurysm Repair: Preliminary Report

Reducing fluoroscopy times and iodine contrast administration during endovascular repair (EVAR) of infrarenal aortic aneurysms remains a challenge. The purpose of this study is to evaluate the preliminary results of a fully ultrasound-assisted EVAR without iodine contrast administration. Twenty-seven consecutive patients underwent an elective intravascular ultrasound (IVUS)-assisted EVAR with final contrast-enhanced ultrasound (CEUS) control of correct aneurysm exclusion. In no case intraprocedural injection of iodine contrast medium was performed. The primary study's end points were the overall duration of the procedure, duration of fluoroscopy, cumulative radiation dose, the length of intraoperative CEUS control, and the comparison of findings between intraoperative CEUS and computed tomography (CT) scan at 1 month. Mean duration of the procedure was 130±35min. Overall duration of fluoroscopy was22±18min. Mean radiation dose was 66mGy (range 24-82). The mean length of CEUS final control was 8±2min. No type I or type III endoleak was detected either at CEUS or at angio-CT scan at 1 month from EVAR. CEUS revealed a type II endoleak in 6 patients (22%), compared to 9 type II endoleaks (33%) detected at angio-CT scan 1 month after the procedure (P=0.5). Fully ultrasound (IVUS and CEUS)-assisted EVAR is safe, feasible, and reliable, completely eliminating the need for iodine contrast medium and reducing the radiation exposure for both patients and surgeons.

Long-term anticoagulation is associated with type II endoleaks and failure of sac regression after endovascular aneurysm repair

ObjectiveWithin the context of endovascular aneurysm repair (EVAR), the role of anticoagulation therapy on endoleak development and subsequent reintervention is unclear with conflicting data in the literature. The hypothesis of this study is that long-term anticoagulation is associated with persistent type II endoleaks and failure of sac regression in patients undergoing endoluminal repair of intact infrarenal aortic aneurysm. MethodsRetrospective cohort abstracted from the Vascular Quality Initiative index hospitalization and long-term follow-up datasets for EVAR (2003-2017) were included in the analysis. Patients not taking aspirin preoperatively and postoperatively were excluded. Patients taking anticoagulation and aspirin concomitantly (treatment) after the index procedure were compared against patients taking aspirin alone (control). Anticoagulation included warfarin and novel oral anticoagulants, including factor Xa inhibitors and direct thrombin inhibitors. One-to-one greedy matching using propensity scores was implemented to match patients. The primary end points were failure of aneurysm sac regression, sac expansion, risk of endoleak, and reintervention rate for endoleak at follow-up. Sac regression was defined as a decrease of at least 5 mm and sac expansion was defined as an increase of at least 5 mm. ResultsThere were 9004 patients who received ASA alone and 332 patients who received ASA and anticoagulation. Propensity scores were used to create 301 matching pairs to account for differences in baseline characteristics and comorbidities, including but not limited to age, sex, smoking, coronary artery disease, heart failure, and chronic kidney disease between the treatment and control groups. After adjusting for covariables anticoagulation use was independently associated with a significantly decreased abdominal aortic aneurysm sac regression (41.59% vs 58.41%; P = .001), but no statistically significant difference in sac expansion with long-term anticoagulation use (9.7% vs 4.9%; P = .056). There was increased risk of type II endoleaks (11.96% vs 6.31%; P = .023; relative risk, 1.89; 95% confidence interval, 1.11-3.23; P = .016), but no significant differences in type I, III, or indeterminate endoleaks. There was no statistical difference in 2-year reintervention rates (4.32% vs 2.66%; hazard ratio, 1.43; 95% confidence interval, 0.55-3.77; P = .461). There were no differences in any primary outcome between warfarin and novel oral anticoagulants. ConclusionsThese data demonstrate that long-term aspirin plus anticoagulation use is associated with a lack of aortic sac reduction and persistent type II endoleak, but not an increased risk for subsequent reintervention. Because prior studies have demonstrated that sac regression is a correlate of survival, these findings associating regression failure suggest a potential therapeutic failure for patients undergoing EVAR who also require long-term anticoagulation therapy. Although not a contraindication, long-term anticoagulation should be considered when counseling patients with a surgical indication aortic aneurysm.