Infrarenal Aortic Aneurysm Research Articles

Use of Physician-Modified Endografts to Repair Unilateral or Bilateral Aortoiliac Aneurysms

This article presents an endovascular approach to repair a unilateral or bilateral aortoiliac aneurysm with a bifurcated iliac limb that can maintain perfusion to the internal iliac artery (IIA) bilaterally through a brachial access. A standard infrarenal aortic aneurysm repair is performed followed by iliac aneurysm exclusion. To obtain exclusion in the common iliac artery aneurysm, a bifurcated Endurant iliac limb is modified to compartmentalize iliac flow 2-3cm above the internal iliac ostia. Then, a balloon-expandable covered stent graft is used to achieve sealing in the IIA and external iliac artery (EIA). The IIA is stented from the arm and the EIA is stented from the groin. There was no in-hospital or 30-day mortality. The procedural design was followed in each of the patients who received treatment. Technical success was 100%, short-term clinical success was 92%, and midterm clinical success was 83%. Average dosage of contrast medium was 116 mL (range, 55-193 mL), and average fluoroscopy time was 42.1 min (range, 20.8-91.6 min). Average length of hospital stay was 2.6 days (range, 1-9 days). There was 1 recorded endoleak. No reports of gluteal claudication, sexual dysfunction, or bowel or spinal claudication have been found. The technique described here does not require an up-and-over approach, allowing simplified bilateral repair. Although this is a promising technique, long-term durability needs to be evaluated in a controlled prospective study.

What Factors Predict Wound Complications after Endovascular Aortic Aneurysm Repair?

s Accepted for Presentation during the 2015 Southern California Vascular Surgical Society Annual Meeting Endoleak after Modular Bifurcated Stent Versus Unibody Stent Graft for Endovascular Treatment of Infrarenal Abdominal Aortic Aneurysm Neha Sheng, Phong Dargon, Jason T. Chiriano, Theodore H. Teruya, Sheela T. Patel, Ahmed M. Abou-Zamzam Jr., and Christian Bianchi Loma Linda, California. Background: The purpose of our study is to report on results of endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA) and postoperative aneurysm sac diameter change, after repair with modular bifurcated and unibody aortic stent grafts. Methods: We retrospectively reviewed a prospectively maintained database of all endovascular aneurysm repair (EVAR) procedures performed for infrarenal abdominal aortic aneurysms (AAA) at a single VA institution. A total of 113 patients underwent EVAR for infrarenal AAA between October, 2008 and November, 2011. Patients were included if they underwent elective EVAR for asymptomatic infrarenal AAA greater than 5 centimeters in diameter, and if preoperative and postoperative imaging was available for review. Patients were assessed with clinical examination and CT scan at 1, 6, and 12 months and yearly thereafter. Results: Fifty patients underwent EVAR with a modular bifurcated graft: Gore Excluder (n 41, 82%), Medtronic Talent (n8, 16%), Cook Zenith (n1, 2%). Sixty-three patients underwent EVAR with the Endologix unibody design stent graft. Thirty-six patients (72%) in the modular bifurcated group met the criteria for the instructions for use (IFU) of the graft inserted (Mod-IFU), and 14 patients (28%) did not (Mod-non IFU). Fifty-two patients (83%) in the unibody group met the IFU criteria (Uni-IFU), and 11 (17%) did not (Uni-nonIFU). Overall follow-up was 20.1 months. Rate of postoperative endoleak was 27.8% in the Mod-IFU group, 28.6% in the Mod-non IFU group, and in 27.3% in the Uni-non IFU group, and 7.7% in the Uni-IFU group. Conclusions: Overall, fewer endoleaks are noted in patients meeting IFU criteria and undergoing EVAR for infrarenal AAA with unibody stent graft design. http://dx.doi.org/10.1016/j.avsg.2015.03.002 870 What Factors Predict Wound Complications after Endovascular Aortic Aneurysm Repair? Michael F. Amendola, Luke Wolfe, Marcella WoogenFisher and John Pfeifer Hunter Holmes McGuire VA Medical Center, Richmond, VA. Introduction: Endovascular aortic aneurysm repair (EVAR) is becoming thepreferredmethod for treating infrarenal aortic aneurysms. The majority of EVAR procedures require a groin incision to access the common femoral artery. Weset forth to examineourEVARpopulation to discover factors that contribute to wound complications post-operatively. Methods: With Institutional Board Review approval, we retrospectively queried our Veterans Administration Hospital operative database to identify male patients who underwent EVAR from January 1, 2010 to December 31, 2012. Each patient’s groin wound was considered individually and no adjunctive procedures were performed at the time of EVAR. All re-operative groins were excluded. Patients were followed for wound infection, wound breakdown, wound revision, and lymphatic leaks. Patients with wound complications (WC) were compared to patients with no wound complication (NWC). Age, body mass index (BMI), operative times, and CT calculated wound depth (CWD) were recorded. CWD was defined as the perpendicular distance measured in centimeters from the common femoral artery just proximal to the profunda femoris artery to the nearest skin edge. Receiver operator correlations were calculated for BMI as compared to CWD. Age, history of hypertension, history of diabetes, pre-EVAR hypogastric intervention, side of wound, incision type (vertical or horizontal) and operative times were also collected. Results: A total of 142 incisions were followed in 71 male patients. There was a 14.8% total wound complication rate. The WC group had a statistically higher BMI and CWD. Age, operative times, history of hypertension, history of diabetes, pre-EVAR hypogastric intervention, side of wound, incision type (vertical or horizontal), operative times, history of smoking and death rates were not statistically different between the two groups. Spearman Correlation Coefficient of 0.80300 (p 50, history of CHF, paraplegia, prior operation in last 30 days, emergent surgery, unplanned reintubation, and septic shock were independently associated with increased 30-day mortality. (table 2). Conclusion: Overall 30-day mortality was not significantly different between the two surgical techniques. However, older patients with more medical comorbidities underwent TEVAR. Age >50, history of CHF, operation in the previous 30 days, emergency surgery, unplanned re-intubation, and septic shock were independent predictors of 30-day mortality. http://dx.doi.org/10.1016/j.avsg.2015.03.004 Endovascular Repair of Mycotic Aneurysms e An Evolving Paradigm Erin Ward, Erik Owens, John Lane and

Potential clinical feasibility and financial impact of same-day discharge in patients undergoing endovascular aortic repair for elective infrarenal aortic aneurysm

The purpose of this study was to evaluate the potential feasibility and financial impact of same-day discharge after elective endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm. All elective EVARs performed between January 2012 and June 2013 were identified. Demographics, comorbidities, complications, nursing care, financial data, and length of stay were analyzed. Sixty-seven (73%) EVARs were performed electively, 73% percutaneously. Intraoperative complications were blood loss requiring transfusion (4.5%), thrombosis (3%), femoral artery injury (1.5%), postoperative urinary retention (4.5%), myocardial infarction (3%), respiratory failure (1.5%), congestive heart failure (1.5%), and hemodynamic or rhythm alterations (37%; evident in 88% <6 hours; 13% required therapy). Monitoring only was needed in 28 patients (42%), intensive care in 15%. Seventy-two percent were discharged on postoperative day one; 6% were readmitted <30 days. Telemetry, oxygen, intravenous hydration, and urinary catheters (routine services) were used for shorter periods in uncomplicated patients and those discharged on postoperative day 1. Total hospital costs were $29,479: operating room, 80.3%; anesthesia, 2.2%; preadmission, 1%; postanesthesia unit, 3.1%; intensive care unit, 1.9%; floor, 4.7%; laboratory and diagnostic tests, 1.2%; pharmacy, 1.4%; other, 4.2%. Total cost was similar for those discharged <20 hours or ≥24 to 31 hours postoperatively (P = .51) and for monitoring only vs others ($28,146 vs $30,545; P = .12). Pharmacy ($351 vs $509; P = .05), laboratory work ($86 vs $355; P = .01), and diagnostic testing ($4 vs $254; P = .02) costs were lower for uncomplicated cases. Same-day discharge is clinically feasible in >40% of elective EVARs but requires coordination for adequate postoperative monitoring. Significant savings are unlikely as most cost is operating room and device related, and further reduction of costs in uncomplicated cases is unlikely.

A Comparison of Two-Dimensional CTA and Three-Dimensional Volumetric CTA Analysis Software Algorithms for Planning Thoracic, Thoracoabdominal, and Infrarenal Aortic Aneurysm Repair

This study compared relevant measurements in two-dimensional (2D) computed tomography angiography (CTA) imaging and semiautomated algorithmic measurements using 3D Volumetric CTA Interpretation software for thoracic, thoracoabdominal, and infrarenal aortic aneurysms. This retrospective study compared data points in 20 patients who underwent standard 2D CTA imaging and 3D CTA Interpretative software imaging for aortic aneurysmal disease. Information gathered was intended for preoperative planning and potential endovascular options. Measurements taken within the 3D CTA Interpretation software was done via a point-and-click method whereby the software algorithmically determines measurements along the aorta and displays them when the region of interest is selected. The software also determines the distance between two points using a centerline through the aorta as a reference. Intraluminal surface irregularities and location of thrombus is determined by direct observation via “drive through” techniques. Standard measurements were taken to include diameter of normal artery proximal and distal, length of neck, and landing zone. Additional criteria were evaluated for all aneurysm types including the presence of a normal artery, intraluminal defects, percentage of thrombus in the neck, and degree of calcification. From the 20 patients in our cohort, we obtained 20 contemporary imaging examination pairs. Bland-Altman analysis was performed and demonstrated that the 2D and 3D mean difference measurements was 0.8 mm. All data groups fell within two standard deviations with a range of 1.96 mm. Intraluminal abnormalities and more accurate vessel wall morphology were obtained with 3D imaging. The accuracy of 3D Volumetric CTA Analysis Software Algorithms in evaluating aneurysmal aortic disease for the purpose of preoperative planning is comparable to that of 2D CTA imaging and frequently provides helpful luminal surface information in preparation of repair.

SS10. Endovascular Treatment of Failed Open Surgical and Bifurcated Stent Grafts and Short-Length Infrarenal Aortic Aneurysms Using Fenestrated-Branched Endografts With Distal Inverted Iliac Limbs

Objectives: Open aortoiliac grafts have been constructed with a short aortic bifurcation sewn near or to the visceral vessels to avoid limb kinking. Similarly, the majority of endovascular bifurcated stent grafts have short aortic main body ranging from 4 to 5 cm. In these patients and in those with short infrarenal aortic lengths, endovascular salvage with fenestrated-branched stent grafts is technically challenging because of the short distance between the renal arteries and the flow divider of the graft. Custom-manufactured fenestrated-branched stent grafts can be extended into the prior open surgical graft or stent graft using a short distal bifurcated stent graft with inverted iliac limb (Fig) for the contralateral gate. The aim of this study was to evaluate outcomes of patients treated with fenestrated-branched stent grafts coupled with inverted iliac limbs for salvage of failed open surgical and endovascular stent grafts. Methods: The clinical data of three high-volume, complex aortic referral centers using fenestrated-branched stent grafts were entered into prospectively maintained databases from January 2011 to June 2014. All patients had investigational manufactured devices under physician-sponsored investigational device exemption protocols. In addition to the proximal fenestrated-branched component, all patients received custom-manufactured distal bifurcated devices constructed with a main body<70 mm and an inverted iliac limb to dock the contralateral gate. End points were technical success, 30-day or in-hospital mortality, type I or III endoleak, limb occlusion, and secondary reintervention. Results: There were 56 patients, 41 males (73%) and 15 females (27%), with mean age of 75 years (range, 5986 years) treated by fenestrated-branched stent grafts using distal bifurcated devices with inverted iliac limbs. Fortyseven patients (84%) had a previous aortic repair with a short main body device and nine had short distances between the native renal artery and aortic bifurcation requiring inverted limbs. A total of 184 visceral arteries were targeted by fenestrations or branches (mean, 3.3 vessels/patient). Technical success was 96.4%, with no 30-day or in-hospital deaths. At a mean follow-up of 11 months, six patients developed endoleaks; however, there were no device migration, occlusions, or complications associated with the inverted limb. On the inverted limb side there were three complications. Two patients developed type IB endoleaks treated by limb extension and angioplasty, and one patient developed distal limb ischemia treated by thrombectomy. Reintervention was successful in all of these patients. Conclusions: Patients with a short distance between the renal arteries and the aortic bifurcation can be challenging for endovascular treatment using currently available devices. The use of inverted limb custom-manufactured devices avoids the need for aortouniiliac repair, with femoralfemoral bypass preserving antegrade contralateral limb perfusion. The device was associated with no migration, component separations, or type III endoleaks. In the short-term, rates of type III endoleak or limb occlusion are similar to what has been reported for universal bifurcated devices with noninverted iliac limbs.

Site-Specific Relationship Between Intracranial Aneurysm and Aortic Aneurysm.

The high prevalence of intracranial aneurysms (IAs) in patients with a bicuspid aortic valve or coarctation of the aorta suggests a link between IA and aortic pathology. However, studies reporting this link do not sufficiently address the heterogeneity of IAs arising from different anatomic locations. This study aimed to explore whether a location-specific relationship exists between the 2 kinds of aneurysms. Retrospective institutional analysis of patients aged ≥18 years with both IA and an aortic aneurysm (AA) was performed from 2005 to 2014. IAs were categorized based on their locations: internal carotid artery, other anterior circulation, and posterior arteries. AAs were classified as ascending, descending, infrarenal, or multiple. We analyzed the clinical characteristics and the distribution of IA in each AA group. Of 2375 patients, 660 with available intracranial angiography were screened for IA. We identified 71 patients with 97 IAs. The frequency of both anterior circulation-IAs and internal carotid artery-IAs differed significantly among the AA groups (P=0.001 and P=0.01, respectively). Anterior circulation-IAs were most frequently observed in ascending AA group and least frequently in infrarenal AA group. In contrast, internal carotid artery-IAs were found mostly in infrarenal AA group, least in ascending AA group. Proportions of patients having anterior circulation-IA and internal carotid artery-IA were also highest in ascending AA group and infrarenal AA group, respectively. The number of posterior arteries-IAs was too small to characterize. The differing distribution patterns of IA among AA groups suggest a site-specific sharing of pathomechanism between the 2 types of aneurysms.

Outcome and risk factor analysis of patients who underwent open infrarenal aortic aneurysm repair

The aim of this study was to evaluate the short- and long-term outcomes in patients who underwent open infrarenal aortic aneurysm repair. Consecutive patients who underwent open repair of infrarenal aortic aneurysms at our institution from July 1(st) 1990 to June 30(th) 2012 were reviewed from a prospective collected departmental database. Short-term outcomes included 30-day mortality and peri-operative complications. Independent risk factors to predict 30-day mortality were identified. Long-term survival and secondary interventions were also reported. Three hundred and eighty-three patients (317 males, median age 72 years with a range of 15-90 years) underwent open infrarenal aortic aneurysm repair during the period, of whom 266 (69.5%) were elective, 18 (4.7%) were urgent for symptomatic but nonruptured cases, and 99 (25.8%) were emergency procedures for ruptured aneurysms. Mean aneurysm size was 6.5cm (ranging from 2.5cm to15cm). All patients were followed up for at least 24 months with a mean follow up period 163 months. Overall 30-day mortality was 11.0% (36.4% for ruptured cases, 11.1% for symptomatic cases, and 1.5% for elective cases; p<0.001). Preexisting renal disease and ruptured aneurysms were independent risk factors for 30-day mortality (p=0.001 and p=0.006 respectively). Systemic complications included 50 cardiac events, 52 respiratory events, six renal events, three cerebral vascular accidents, and one deep vein thrombosis/pulmonary embolism. Local complications included two anastomotic/graft hemorrhage, 10 distal thrombosis/embolisms, five bowel ischemias, one spinal cord ischemia, and 17 wound complications. The ruptured group presented survival rates of 53.5%, 50.5%, 47.5%, 42.3%, 38.0%, 21.9%, and 12.5% at 1 year, 2 years, 3 years, 4 years, 5 years, 10 years, and 15 years, respectively; while nonruptured survival rates were 91.5%, 88.0%, 83.7%, 78.3%, 73.0%, 43.0%, and 25.3%, respectively (log rank p<0.001). For those who died 30 days after the operation, only six patients (1.8%) died from aneurysm related mortality. A total of three (0.9%) patients underwent late re-interventions, one for late aorto-enteric fistulae and two for anastomotic pseudoaneurysms. In the current era of endovascular repair, open infrarenal aneurysm repair is effective and durable, and has very low secondary interventions rates.

Urgent endovascular repair for ruptured aortic aneurysm using computed tomography image fusion

Abdominal aortic aneurysm rupture remains a cardiovascular catastrophe with strikingly high morbidity and mortality rates. Endovascular aneurysm repair management has recently emerged as a valuable treatment modality for ruptured abdominal aortic aneurysm, but better outcomes have to be reached. Image fusion may potentially improve perioperative outcomes in selected patients, guiding navigation and device implantation and limiting contrast dosage during interventions. We report an 83-year-old man presenting with an 80-mm infrarenal aortic aneurysm rupture suitable for endovascular aneurysm repair. Endovascular navigation and stent graft deployment were achieved using computed tomography image fusion for the first reported case in English.

Percutaneous interventions in aortic disease.

Percutaneous access techniques for diagnostic and therapeutic approaches to the coronary and aortic branch vessels have been the mainstay of cardiovascular interventions for several decades. The development of catheter-based technologies to treat traumatic and degenerative pathology of the thoracic and abdominal aorta initially required the use of direct femoral access via open incisions because of the size of the devices and their delivery sheaths. Although the endovascular repair of infrarenal aortic aneurysms (EVAR)1 ushered in an entirely new concept for managing aortic pathology, there was a concomitant development of a new series of complications associated with open vascular access. Of the devices approved by the US Food and Drug Administration, the profiles of the currently available components ranges from 9F to 25F inner diameter, which correlates to 11F to 27F outer diameter. In particular, delivery systems for thoracic endografts have 22F to 27F outer diameter and are traditionally placed via femoral artery cut-down or surgically created conduits. With the evolution of devices with smaller sheaths, the development of closure devices, and noninvasive imaging studies to assess the suitability of arteries for percutaneous access, there have been major changes in the approach and timing of aortic interventions. Over the years, many closure devices have been marketed to decrease the need for manual compression or reversal of anticoagulation after transfemoral percutaneous diagnostic or therapeutic interventions. To date, only suture-mediated closure devices have been used to manage larger catheter-based percutaneous interventions. Two suture-mediated percutaneous closure devices currently are available for potential off-label use in the closure of endograft access sites: Perclose Prostar XL and Perclose ProGlide (Abbott Vascular, Redwood City, CA). The Perclose Prostar XL device comes in 2 different sizes. The Prostar XL 8 is designed for closure of 6.5F to 8F access sites, and Prostar XL 10 is for closure …

Survival Comparison of Patients Undergoing Secondary Aortic Repair

Introduction. Infrarenal abdominal aortic aneurysm (AAA) repair warrants lifelong surveillance. Secondary aortic intervention (SAI) outcomes may be affected by the therapeutic approach. We compared short- and long-term mortality in patients who underwent SAIs after initial aortic repair, either endovascular (EVAR) or open. Methods. Patients who underwent AAA repair between 1986 and 2010 were retrospectively identified in a vascular surgery database as well as those who underwent SAIs. All-cause mortality and Kaplan-Meier survival curves were calculated. Results. We identified 149 patients who underwent either open AAA repair or EVAR followed by open or endovascular SAI. Seventy-seven patients (51.7%) underwent initial EVAR while 72 patients (48.3%) underwent open repair. Sixty (78%) initial EVAR patients underwent secondary EVAR while 17 (22%) patients had an open SAI. Initial open repair patients were evenly distributed between EVAR and open SAIs. Compared to EVAR, patients who underwent initial open repair had longer intervals between primary aortic interventions (PAIs) and SAIs. Multivariable-adjusted all-cause mortality was significantly higher for patients who underwent initial open AAA repair followed by EVAR when compared to patients who underwent endovascular PAI and SAI. Conclusion. Long-term mortality in patients with infrarenal aortic aneurysms who require SAI may be improved by an EVAR-first algorithm.

Initial experience of follow up of patients after the endovascular treatment of abdominal aortic aneurysms using contrast-enhanced ultrasound

IntroductionAll patients who underwent the endovascular treatment of abdominal aortic aneurysm require regular check-ups for possible occurrence of endoleak and further growth of the aneurysm. Such check-ups are performed in most cases by CT imaging with the administration of a contrast agent which may cause allergies or impairment of renal functions. CT itself represents a significant radiation dose incurred by the patient. When contrast-enhanced ultrasound (CEUS) is used, patients are exposed neither to these risks nor to X-ray radiation. ObjectiveVerify the diagnostic recovery of contrast-enhanced ultrasound for the monitoring of patients after the endovascular treatment of abdominal aortic aneurysms. MethodSince January 2014 we have been qualifying patients for a prospective study. All patients who have been implanted a stent graft for the infrarenal aortic aneurysm since January 2014 and patients who were implanted a stent graft earlier but who have undergone a check-up since January 2014 are qualified for the study. These patients are always checked up after the surgery by CT angiography and CEUS as well. 16 patients have been qualified for the study so far. After the application of a stent graft we examine our patients before they are discharged from the hospital and 1, 6 and 12 months after the surgery. CEUS is performed by 2 physicians only. ResultsIn the 16 patients a total of 28 check-ups have been conducted (1 check-up without contrast medium). In 9 patients (13 CTA examinations and 12 CEUS) endoleak was proven (1 of the I-type, 8 of the II-type). In the case of 2 examinations consistency between CTA and CEUS was not proven – 7.4%. In one case the inconsistency concerned the type of endoleak and in the other case, CTA erroneously described endoleak which was not obvious from CEUS. When measuring the size of an aneurysm sack, we observed significant differences between CTA and CEUS (p<0.001). The CEUS examination was assessable even in the case of obese patients. ConclusionWe have observed a 100% consistency in the result of 25 examinations which used both methods. Based on the comparisons between CEUS and CTAG performed so far, CEUS seems to be a reliable method which could be used within the framework of dispensary care for patients after endovascular aneurysm repair (EVAR). CEUS seems to be sensitive enough to detect endoleak. However, to be able to provide a reliable evaluation, a larger set of patients and longer-term experience are needed, specifically for the evaluation of the aneurysm sack size.

Lessons learned from the endovascular management of blunt thoracic aortic injuries: A single-centre experience.

Blunt thoracic aortic injuries (BTAIs) remain a leading cause of death after blunt trauma. In severe injuries, thoracic endovascular aortic repair (TEVAR) has provided a less invasive alternative to conventional open repair. To report the TEVAR-related complications and uncertainties in patients who presented with traumatic pseudoaneurysms (grade III BTAI). From April 2004 to February 2012, 55 patients (42 male, mean age 34.7 years) with severe BTAI were treated with stent grafts. Computed tomography (CT) was used to diagnose the injuries, and follow-up scans were planned at 6 and 12 months. We report the complications and the technical uncertainties related to the procedure. Successful sealing of the injury sites was achieved in all patients, either with a thoracic stent graft (53/55) or infrarenal aortic aneurysm extender cuffs (2/55). During hospitalisation, 13 patients died after TEVAR (mean 14 days). Procedure-related complications included left common carotid artery coverage (1/55), ischaemic left leg (1/55) and graft collapse (1/55). The procedurerelated uncertainties included excessive graft oversizing (15/55), poor graft apposition to the inner curve of the aorta (19/55) and left subclavian artery coverage (24/55). Stent grafts appear safe and effective in treating pseudoaneurysms caused by BTAI. However, they are likely to be associated with long-term complications and monitoring strategies of >30 years may be necessary.

The benefit of early repair for a mycotic aortic aneurysm due to Yersinia enterocolitica infection

Mycotic aortic aneurysms are infrequent but challenging cases. We present a 68-year-old man with evolving infrarenal aortic and right common iliac artery aneurysms from an infection with Yersinia enterocolitica. This is a rare but virulent cause of aortitis. The patient underwent open resection and debridement with anatomic reconstruction using an aortic homograft. He recovered well and quickly returned to normal functional status. This represents the first successful anatomic aortic repair using homograft with this organism. Here, we review the literature and outcomes associated with this unusual pathogen. With favorable anatomy and expedient operative management, good results can be obtained.

Outcomes of endovascular abdominal aortic aneurysm repair in high-risk patients

Although the endovascular aneurysm repair trial 2 (EVAR-2) demonstrated no benefit of EVAR in high-risk (HR) patients, EVAR is still performed widely in this patient cohort. This study compares the midterm outcomes after EVAR in HR patients with those in normal-risk (NR) patients. In turn, these data are compared with the EVAR-2 data. A retrospective review from January 2006 to December 2013 identified 247 patients (75 HR [30.4%], 172 NR [69.6%]) who underwent elective EVAR for infrarenal aortic aneurysm in an academic tertiary institution and its affiliated Veterans Administration hospital. The same HR criteria used in the EVAR-2 trial were employed. Overall survival, graft-related complications, and reintervention rates were estimated by the Kaplan-Meier method. HR group outcomes were compared with the EVAR-2 data. HR patients had a larger abdominal aortic aneurysm size and had a higher prevalence of cardiac disease (P < .01), chronic obstructive pulmonary disease (P = .02), renal insufficiency (P < .01), and cancer (P < .01). Use of aspirin (63% HR vs 66% NR; P = .6), statin (83% HR vs 72% NR; P = .2), and beta-blockers (71% HR vs 60% NR; P = .2) was similar; in the EVAR-2 trial, the corresponding use of these medications was 58%, 42%, and not available, respectively. Perioperative mortality (0% HR vs 1.2% NR; P = 1.0) and early complication rates (4% HR vs 6% NR; P = .8) were similar. In contrast, perioperative mortality in the EVAR-2 trial was 9%. At a mean follow-up of 3 years, the incidence rates of delayed secondary interventions for aneurysm- or graft-related complications were 7% for HR patients and 10% for NR patients (P = .5). The 1-, 2-, and 4-year survival rates in HR patients (85%, 77%, 65%) were lower than those in NR patients (97%, 97%, 93%; P < .001), but this was more favorable compared with a 36% 4-year survival in the EVAR-2 trial. No difference was seen in long-term reintervention-free survival in HR and NR patients (P = .8). Backward stepwise logistic regression analysis identified five prognostic indicators for post-EVAR death: age, chronic kidney disease stages 4 and 5, congestive heart failure, home oxygen use, and current cancer therapy. EVAR can be performed in patients unfit for open surgical repair with excellent early survival and long-term durability. These outcomes in the HR group compare more favorably to the EVAR-2 trial data. However, not all HR patients for open surgical repair derive the benefit from EVAR. The decision to proceed with EVAR in HR patients should be individualized, depending on the number and severity of risk factors.

Role of type II endoleak in sac regression after endovascular repair of infrarenal abdominal aortic aneurysms

Endovascular repair (EVAR) of infrarenal aortic aneurysms (AAA) is increasingly used in patients with suitable aortic morphology conforming to device-specific instructions for use. Despite improvements in graft design, type II endoleak (EL-2) from the inferior mesenteric artery (EL-IMA) or the lumbar artery (EL-LA) remains the Achilles' heel of EVAR. The objective of this study was to evaluate the natural history of the AAA sac after EVAR. We hypothesized that persistent EL-2 would be associated with inferior AAA sac volume regression. A retrospective analysis was performed on all nonruptured AAA treated by elective EVAR using Food and Drug Administration-approved endografts from January 2005 to December 2008 in our facility. Review of medical records and preoperative and follow-up computed tomography angiograms at 1, 6, and 12 months was performed. Patients with type I, III, and IV endoleaks were excluded, as were those lost to all follow-up. AAA size and volume were analyzed using TeraRecon software (Aquarius Intuition, Foster City, Calif). Change in AAA sac volume was compared in patients with and without EL-2, and with an occluded vs patent IMA. The study cohort comprised 191 patients (161 men, 30 women) with a mean age of 74 years. The mean preoperative AAA diameter was 5.5 cm (range, 4-11 cm), and mean volume was 137.45 cm(3). EL-2 was present in 24% at completion of EVAR and in 9% at a mean follow-up of 6 months (range 4-8 months). Completion angiography at 1 month showed 63% of EL-2 had resolved. Those with EL-2 present at 1 month had statistically inferior sac regression compared with those who did not (23% reduction vs 2% increase at 1 year; P = .002). Preoperatively, the IMA was occluded by coils or was chronically occluded in 82 patients vs 109 patients who had a patent IMA. At the 6-month follow-up, patients with an occluded IMA had an EL-2 rate of 2.4% vs 14.7% in those with a patent IMA (P = .005 by t-test). Sac volume regression was 21.8% in those with an occluded IMA vs 13.2% in those with a patent IMA (P = .004 by t-test). Regression in AAA sac volume was highly significant in patients with occluded IMA, at 30% vs 16% at 1 year (P = .0018 by two-sided t-test). The presence of persistent EL-2 after EVAR results in inferior AAA sac regression. A preoperatively patent IMA is associated with increased rates of EL-2 and inferior AAA sac regression. Consideration should be given to preoperative occlusion of a patent IMA before EVAR.

Induction of continuous expanding infrarenal aortic aneurysms in a large porcine animal model.

BackgroundA large animal model with a continuous expanding infrarenal aortic aneurysm gives access to a more realistic AAA model with anatomy and physiology similar to humans, and thus allows for new experimental research in the natural history and treatment options of the disease.Methods10 pigs (group A) underwent infrarenal aortic dissection, balloon dilatation, infusion of elastase into the lumen and placement of a stenosing cuff around the aorta. 10 control pigs (group B) underwent a sham procedure. The subsequent 28 days the AP-diameters of the aneurysms were measured using ultrasound, hereafter the pigs were euthanized for inspection and AAA wall sampling for histological analysis.ResultsIn group A, all pigs developed continuous expanding AAA's with a mean increase in AP-diameter to 16.26 ± 0.93 mm equivalent to a 57% increase. In group B the AP-diameters increased to 11.33 ± 0.13 mm equivalent to 9.3% which was significantly less than in group A (p < 0.001). In group A, a significant negative association between the preoperative weight and the resulting AP-diameters was found. Histology shoved more or less complete resolution of the elastic tissue in the tunica media in group A. The most frequent complication was a neurological deficit in the lower limbs.ConclusionIn pigs it's possible to induce continuous expanding AAA's based upon proteolytic degradation and pathological flow, resembling the real life dynamics of human aneurysms. Because the lumbars are preserved, it's also a potential model for further studies of novel endovascular devices and their complications.

Preclose Percutaneous Endurant™ Endografting with the Proglide™ Device: a Safe and Feasible Combination

Background : Endovascular repair of abdominal aortic aneurysms has been revolutionized over the last two decades. Opening the doors for a percutaneous approach by avoiding surgical exposure of the vascular access site. The goal of this report is to analyze the feasibility and efficacy of using Perclose Proglide™ through a preclose technique in a percutaneous approach to Endurant™ endografting for Asymptomatisch infrarenal aortic aneurysms in an elective setting. Methods : Between April 2011 and April 2014, 45 consecutive patients underwent percutaneous endovascular aortic aneurysm repair (PEVAR) for an asymptomatic infrarenal aortic aneurysm. Closure of percutaneous access sites was ensured with Perclose Proglide in a “preclose” technique. Data were collected in a prospective maintained database with a follow-up period of one month. Patient demographics, aneurysmal characteristics, procedural details and complications were recorded.Results : A total of 170 Proglide devices were used to close 85 access sites. Adequate hemostasis was obtained in 96.5 percent (82 of 85 access sites). Conversion to a femoral cutdown was necessary in 2.4% (2 of 85 access sites). The mean hospitalization was 2.6 days and 86.7 percent of patients were discharged within 2 days. The incidence of post-procedural access-related complications was 2.2%.Conclusions : PEVAR using the Perclose Proglide in preclosing 14Fr to 20Fr access sites for Endurant endografting in the treatment of asymptomatic infrarenal aortic aneurysms is feasible and effective. Moreover, the percutaneous approach allows for procedures to be performed under local anesthesia, while providing a low risk for access-related complications and a relatively short hospitalization.

Features of completely percutaneous infrarenal aortic aneurysm stent-grafting

Features of completely percutaneous infrarenal aortic aneurysm stent-grafting

Endovascular Aortic Aneurysm Repair for Type - III Abdominal Aortic Aneurysm Following Aortic Neck Reconstruction with an External Cuff - Making the Unsuitable Neck Anatomy Suitable!

We report a case of infra-renal aortic aneurysm which was not suitable for standard endovascular aneurysm repair. Unsuitable neck was reconstructed by dacron graft cuff around the neck with fixing sutures. Following this, standard EVAR was performed.

A rare case of ruptured infrarenal aortic aneurysm infected with Haemophilus influenzae type B.

CASE PRESENTATION A 56-year old woman presented to the emergency department with a vague history of abdominal pain that had persisted for five days. A long-standing smoker, she was otherwise healthy with no previously diagnosed chronic medical conditions, and had no recent exposure to any sick contacts; she did admit to having a short episode of an upper respiratory tract infection two weeks previously that self-resolved. There was also no recent history of travel. On examination, she was tachycardic (110 beats/min to 115 beats/min), hypertensive (169/110 mmHg) and afebrile, and had a soft but tender abdomen. White blood cell count was in the 20×109/L range. Computed tomography (CT) angiography of the abdomen and pelvis revealed a 4 cm infrarenal aortic aneurysm extending to the aortic bifurcation with an associated 6.4 cm × 10 cm periaortic hematoma suggestive of rupture (Figure 1). The renal arteries and visceral vessels displayed mild atheromatous changes; other intra-abdominal structures were unremarkable. The patient’s relatively young age and female sex, coupled with the relatively small size and inflammatory appearance of the ruptured aneurysm on CT scan, were highly suggestive of a mycotic aneurysm. Blood cultures were drawn and ciprofloxacin and cefazolin were initiated. The patient was brought to the operating room for emergent open repair through a midline transperitoneal approach. Intraoperatively, note was made of an edematous retroperitoneum and an adherent duodenum. There were significant inflammatory changes in the aorta, extending distally into the iliac arteries. The periaortic fluid was noted to be nonpurulent; a sample of this was sent for Gram stain, and was reported as “moderate polymorphs with no organisms seen”. Given these nonspecific findings, the aneurysm was repaired with an in situ aorto-bi-iliac 12 mm × 7 mm Hemashield graft. The patient was then transferred to the intensive care unit (ICU) for postoperative care and continued on ciprofloxacin and cefazolin. Recovery was complicated, however, with acute occlusion of the graft. The patient underwent a second surgery with extensive thrombectomy of both limbs of the graft, as well as a left iliofemoral bypass due to consistently poor flow. The patient continued to decline, requiring increasing pressors to maintain hemodynamics. Antibiotics were broadened to include meropenem, vancomycin and fluconazole to treat her sepsis, despite negative blood cultures drawn at the time of the initial presentation. Additional complications included the need for hemodialysis for renal failure.