Infrarenal Aortic Aneurysm Research Articles

Clinical Presentation, Operative Management, and Long-Term Outcome of Rupture After Previous Abdominal Aortic Aneurysm Repair

Late abdominal aortic aneurysm rupture (LAR) after open or endovascular repair is uncommon but life-threatening. In the present study, we characterized the presentation trends, intervention, and survival after LAR. We performed a single-center, retrospective study of patients who had undergone LAR repair from 2000 to 2020. The endpoints were 30-day mortality, major postoperative complications, and survival. We compared the outcomes between LAR managed with endovascular aortic aneurysm repair (EVAR; group I) vs open surgical repair (OSR; group II). Of 390 patients with infrarenal aortic aneurysm rupture, 40 (10%) had undergone prior aortic repair and comprised the LAR cohort (34 men; mean age, 78 years; initial EVAR for 29; initial OSR for 11). LAR had occurred despite reintervention in 13 patients (44%). Endoleaks had developed in 26 patients and were type I in 21 patients (72%), type III in 3 patients, (10%) and type II in 2 patients (3%). Ten patients (29%) were lost to follow-up. LAR after prior OSR was secondary to ruptured para-anastomotic pseudoaneurysms, which were managed with endovascular salvage in nine patients. The time to LAR was shorter after prior EVAR compared with after OSR (6 ± 4 vs 12 ± 4 years, respectively; P = .003). Treatment of LAR was EVAR for 27 patients (67%; group I) and OSR for 14 (35%; group II). EVAR was more frequent in the latter one half of the study period (Fig). In group I, fenestrated repair had been used for seven patients (26%). Salvage for the rest was feasible with EVAR, aortic cuffs, or limb extensions. The incidence of free rupture, time to treatment, 30-day mortality, and disposition was similar between the two groups. Those in group I had had less blood loss (660 vs 3000 mL; P < .001) and need for dialysis (0% vs 33%; P < .001) than those in group II. The median follow-up was 20 months (interquartile range, 6-45 months). The 1-, 3-, and 5-year survival was 76%, 52%, and 41%, respectively, and was similar between the two groups (28 vs 22 months; P = .92). LAR after abdominal aortic aneurysm repair has become increasingly common, likely resulting from the frequency of EVAR. Most LARs, including those occurring after previous OSR, can be now be salvaged with endovascular techniques with lower morbidity and mortality.

External iliac artery extension causes greater aneurysm sac regression than the bell-bottom technique or iliac branch endoprosthesis for repair of concomitant infrarenal aortic and iliac artery aneurysm

ObjectiveAneurysmal extension of abdominal aortic aneurysms (AAAs) to the common iliac artery (CIA) presents a technical challenge to successful endovascular abdominal aortic aneurysm repair (EVAR). In the present study, we compared sac shrinkage and perioperative outcomes after the bell-bottom technique (BBT), internal iliac artery embolization and external iliac artery extension (EIE), and iliac branch endoprosthesis (IBE). MethodsUsing the Vascular Quality Initiative database, a retrospective analysis was conducted for patients who had undergone EVAR from 2013 to 2019. The demographic, anatomic, and perioperative data were analyzed. All patients with a proximal aortic neck length <10 mm and aortic graft diameter >32 mm were excluded from the analysis. The patients were subdivided into four groups according to the distal limb strategy: group 1, control group with a bilateral common iliac artery limb <20 mm; group 2, BBT with either a unilateral or bilateral limb >20 mm; group 3, EIE technique; and group 4, IBE. The primary endpoint was the maximal change in the aortic diameter during follow-up. The secondary endpoints included postoperative complications and the rate of endoleak. ResultsThe records for 14,455 patients who had undergone EVAR were queried and 5788 met the anatomic criteria. The average age was 73 years, and 86.3% were men. The maximal change in the aortic diameter in the control, BBT, IBE, and EIE groups was −7.2 mm, −6.1 mm, −4.6 mm, and −6.8 mm, respectively (P = .06). The differences were not statistically significant on univariate analysis at an average follow-up of 405 days. However, on multivariable analysis (P = .01), compared with the control group, the BBT and IBE groups were 18.4% (odds ratio [OR], 0.816; 95% confidence interval [CI], 0.68-0.98) and 48.0% (OR, 0.52; 95% CI, 0.33-0.82) less likely to experience aneurysmal shrinkage, respectively. In contrast, the EIE group showed no significant difference in shrinkage compared with that in the control group. Multivariable analysis of the groups also revealed that compared directly with the BBT group, the EIE group was 69.5% more likely to have experienced shrinkage in the aortic aneurysmal diameter (OR, 1.70; 95% CI, 1.05-2.75). The BBT and IBE groups had a significantly higher rate of type II endoleaks (17.63% and 16.95%, respectively; P = .03). The EIE group had a higher rate of type Ib endoleaks (1.9%) compared with the BBT (1.1%), IBE (1.7%), and control (0.3%) groups (P = .01). No differences were found between the groups in terms of postoperative myocardial infarction (P = .47) or respiratory (P = .61) or intestinal (P = .71) complications. However, the rates of limb complications and reoperation were higher in the EIE group. ConclusionsThe present study revealed that the EIE technique was more likely to demonstrate shrinkage in the aortic aneurysmal diameter than were the BBT and IBE groups compared with the control group on multivariable analysis. The EIE technique was also more likely to result in aneurysmal sac shrinkage than was the BBT group, albeit with greater rates of limb-related complications.

Surgical repair of abdominal aortic aneurysms on the public health system in the largest city in Brazil: a descriptive analysis of in-hospital data on 2693 procedures over 10 years.

BackgroundFrom 1990 to 2015, mortality from aortic aneurysms increased 16.8% in Brazil. São Paulo is the largest city in Brazil and about 5 million people depend on the public health system there.ObjectivesTo conduct an epidemiological analysis of abdominal aortic aneurysm surgeries in the city of São Paulo.MethodsInfra-renal aortic aneurysm procedures performed over a decade (from 2008 to 2017) were studied using publicly-available platforms from the Unified Health System and DATASUS.Results2693 procedures were analyzed; 66.73% were endovascular; 78.7% of patients were male; 70.7% were aged 65 years or more; 64.02% were elective hospital admissions. There were 288 in-hospital deaths (mortality: 10.69%). In-hospital mortality was lower for endovascular surgery than for open surgery; both for elective (4.13% versus 14.42%) and urgent (9.73% versus 27.94%) (p = 0.019) admissions. The highest volume hospital (n = 635) had the lowest in-hospital mortality (3.31%). USD 24,835,604.84 was paid; an average of $ 2,318.63 for elective open, $ 3,420.10 for emergency open, $ 12,157.35 for elective endovascular and $ 12,969.12 for urgent endovascular procedures. Endovascular procedure costs were statistically higher than the values paid for open surgeries (p <0.001).ConclusionsEndovascular surgeries were performed twice as often as open surgeries; they had shorter hospital stays and lower mortality.

Effectiveness of ultrasound in the differential diagnosis of ileitis detected by computed tomography.

CASE REPORT A 86-year-old man with a recent history of stent placement for infrarenal aortic aneurysm arrives to the emergency department with abdominal pain. Computed tomography (CT) is performed to rule out complications of the endovascular procedure. The CT showed a loop of ileum with decreased caliber, fat trabeculation and hypervascularity causing proximal dilatation. No signs of ischemia or complications related to the prosthesis were observed. He was admitted to our service due to findings of non-specific ileitis. An intestinal ultrasound was performed and revealed a short segment of proximal ileum with pathological wall thickening with an intraluminal birefringent filamentary hyperechoic material (foreign body), which crossed all the layers of the wall. In the following days serial ultrasounds were performed showing that the foreign body remained in the same location and it was decided to perform surgery. During surgery the foreign body turned out to be a blister which conditioned an ileitis. Finally, intestinal resection was performed and the patient presented good clinical evolution. DISCUSSION The most validated technique for the diagnosis of foreign bodies is CT (1). However, intestinal ultrasound could help in its identification, especially for the non-radiopaque ingested material. On the other hand, it is especially useful in the pediatric age, where exposure to ionizing radiation should be avoided (2,3). In our case, it allowed not only to establish the diagnosis immediately but also to evaluate the evolutionary behavior of the same in terms of its mobilization or detection of local complications.

Comparative study between Endovascular versus Open surgical management of Infra-renal Aortic Aneurysm

Comparative study between Endovascular versus Open surgical management of Infra-renal Aortic Aneurysm

Abstract 9713: Ketosis Decreases Murine Plaque and Aortic Aneurysm Formation

Introduction: Atherosclerosis and aortic aneurysm (AA) are associated with leading causes of mortality worldwide. There is no medical therapy for the treatment of AA, and though diet modification is essential for the management of cardiovascular disease. A ketogenic diet has been accepted as an effective complementary treatment for hypertension and dyslipidemia. Hypothesis: We sought to evaluate if a high fat, low carbohydrate diet could attenuate plaque and AA formation in a mouse model. Methods: Apo E -/- mice (N=30) 12 weeks old, underwent Angiotensin II pump administration, with daily provision of β-aminopropionitrile (BAPN) over 28 days. Control mice (StD, N=15) received a standard diet (fat 42%, carbohydrates 42.7%, proteins 15.2%); while mice undergoing ketosis induction (KD, N=15) received a high fat, low carbohydrate diet (fat 90.5%, carbohydrates 0.3%, proteins 9.2%). Ketosis was achieved by a β-hydroxybutyrate (BHB) whole blood level &gt;0.5 mmol/L. After 28 days, aortic diameters were measured by surgical microscopy. Isolated whole aortas were en-faced and stained with oil red O (ORO) to assess the grade of lesion area (plaque area + aneurysm degeneration area / whole aorta’s area) and plaque content (plaque area / whole aorta’s area). Results: KD mice remained in a ketotic state throughout the experiment. Thoracic and infrarenal AAs were identified in 60% and 74% of StD mice, respectively; however, only 13% and 33% of KD mice developed thoracic and infrarenal AAs, respectively. ORO staining (Fig. 1C and G) demonstrated a significantly smaller lesion area in KD mice (p = 0.04), (Fig. 1D). Furthermore, KD plaque content was attenuated in each segment of the aorta yet only significant in the thoracic aorta (p = 0.04), (Fig. 1H). Conclusions: Our results demonstrate that a ketogenic diet can attenuate the development of atherosclerotic plaque and AA degeneration in mice.

Effect of vertebral compression fractures on aortic neck angulation after endovascular aneurysm repair

ObjectiveAortic neck angulation (ANA) prior to endovascular aneurysm repair (EVAR) and its changes after EVAR are considered important predictors of postoperative complications. We sought to assess the effects of vertebral body height loss on ANA in patients post-EVAR. MethodsAll patients who had undergone EVAR for infrarenal aortic aneurysms in our institution between August 2010 and December 2018 were assessed. Anterior and posterior vertebral body heights were measured in all patients on preoperative, early postoperative, and follow-up computed tomography scans (T12-L5 vertebral bodies). Patients who had significant height loss in their follow-up period were designated as the Study group. These were matched to a Control group of the same size using propensity-score matching based on age, gender, and duration between follow-up scans. Aortic neck morphology indices including ANA and its changes were measured, and information related to postoperative endoleaks and aneurysm sac size were extracted in the Study and Control groups. ResultsDuring the follow-up period, 10 of 185 patients had a radiologically significant vertebral body compression fracture. There was no significant difference between the Study (n = 10) and Control groups in age (77.6 ± 6.9 vs 77.2 ± 7.5 years; P = .64), gender (seven males and three females in each group; P = 1.0), duration between postoperative scans (1830 ± 665 vs 1800 ± 670 days; P = .25), preoperative ANA (36.0° ± 15.6° vs 42.4° ± 18.6°; P = .41), and early postoperative ANA (21.9° ± 11.7° vs 20.9° ± 16.3°; P = .72). Changes in ANA in the postoperative period (7.2° ± 11.1° vs −4.7° ± 6.7°; P = .009; power = .838) were significantly higher in the Study group. ConclusionsPost-EVAR vertebral body compression fractures exacerbate ANA. Awareness of this can guide both preoperative assessment and postoperative management and follow-up.

Fabric Failure: an Old Problem in Modern Stent Grafts

An 84 year old man was admitted as an emergency with abdominal and lower back pain. Four years previously, his infrarenal aortic aneurysm had been repaired endovascularly (Endurant II, Medtronic Cardiovascular, Santa Rosa, CA, USA) and inferior mesenteric and lumbar artery type II endoleaks had been treated by embolisation. (A) Computed tomography angiography showed an 11 cm infrarenal abdominal aneurysm perfused by a probable endoprosthesis defect (arrow). (B) The endoprosthesis main body was surgically explanted and showed a hole which caused the endoleak (arrow). The aorta was reconstructed with a dacron prosthesis (InterGard Silver, InterVascular, La Ciotat, France).Image 1

Long-term results of treatment of infrarenal aortic aneurysms with low-profile stent grafts in a multicenter registry

ObjectiveIn recent years, manufacturers have developed new stent grafts with lower profiles to increase the endovascular aneurysm repair applicability. As reported by the current European Society for Vascular Surgery guidelines, long-term evaluation of such low-profile platforms is strongly recommended. This study aims to report outcomes beyond 5 years from a multicenter registry, including a real-world cohort of patients electively treated with low-profile stent grafts. MethodsA retrospective data collection of patients who had undergone elective implantation of low-profile endograft ≤16 Fr. (Zenith LP, Ovation, Incraft) was performed in nine centers. The primary endpoint was a long-term primary clinical success. Secondary endpoints were survival rate, freedom from abdominal aortic aneurysm (AAA)-related death, freedom from type I to III endoleak, limb patency, and freedom from all reinterventions. The Kaplan-Meier curves were stratified for investigative devices. A multivariate analysis evaluated predictors of primary clinical success and reintervention rate. ResultsA total of 619 patients were enrolled (Ovation, n = 373; Incraft, n = 111; and Zenith LP, n = 135), with a mean follow-up of 56.8 ± 22.8 months. The overall primary and the secondary clinical success rate at 8 years was 72.1% and 93.8%, respectively. At 8 years, overall survival was 53.2%, freedom from AAA-related death was 94.4%, freedom from reintervention was 74%, freedom from type I/III endoleak was 86.9%, and limb patency was 90.4%. A significantly worse primary clinical success of the Zenith LP was recorded as dependent on more limb-related events. No differences between platforms were registered in the rate of AAA-related deaths, open conversion, sac enlargement, and type I/III endoleaks (P = .26). Multivariate analysis identified iliac tortuosity (hazard ratio, 2.053) and Zenith LP (hazard ratio, 3.818) as significant independent predictors of clinical failure and reintervention. ConclusionsLow-profile stent grafts have acceptable long-term outcomes. Overall survival and AAA-related death were in line with those reported for traditional devices. Long-term surveillance and reintervention, when necessary, remain crucial to guarantee durability.

Use of Chimney Technique Does Not Improve the Outcome of Endovascular Aneurysm Repair in Patients With a Hyperangulated and Short Proximal Aortic Neck

Purpose: We hypothesized that extending the proximal landing zone with the chimney technique could be beneficial in patients with a hyperangulated proximal aortic neck, defined as more > 60 degrees. Material and Methods: We retrospectively analyzed the outcome of prospectively collected data of patients treated by endovascular aneurysm repair (EVAR) for infrarenal aortic aneurysm with a hyperangulated proximal aortic neck. In all, 104 out of 130 patients were treated without (Group A) and 24 with the chimney endovascular aortic repair (ChEVAR, Group B). Primary outcome was technical and clinical success according to the reporting standards of the Society of Vascular Surgery. Results: The use of the chimney technique was associated with a significantly longer operation duration (167 vs. 93 min, p < .001), longer fluoroscopy time (44 vs.30 min, p = < .001), and larger amount of contrast medium used (149 vs. 127 ml, p = .03) but did not significantly improve technical (79.2% vs. 87.7%) and clinical success (54.2% vs. 68.9%). Aneurysm-related mortality was higher in group B (8.3% vs. = 0%, p < .001). Type IA endoleak was high in both groups at completion angiography (11.3% in Group A vs. 12.5% in Group B) and at follow-up (10.4% in Group A vs. 4.5% in Group B) without significant difference between the groups. Conclusions: Our data did not show a benefit of the primary use of the chimney technique in patients with a hyperangulated and short neck, although more studies are required to support this conclusion. Other strategies or new technologies are required for improving EVAR results in aneurysm patients with severe angulated proximal and short neck.

Debate on Infrarenal AAA in Young and Fit Patients ('Fit for Open Repair'): Open Repair is Safe and Long-term Results are Better

Endovascular aortic repair, initially developed for patients at prohibitively high risk for an open repair, has undergone significant technical evolution and refinement and has emerged as the preferred treatment option for patients with an infrarenal aortic aneurysm. However, analysis of long-term data of the randomised studies revealed inferior results with regards to survival and freedom-from-reintervention after eight years. Open aortic repair has been performed for more than seven decades and especially for the younger patients with few comorbidities, results are excellent. Potential drawbacks of open repair like incisional hernias, erectile dysfunction and quality of life can either be effectively prevented (mesh reinforcement) or actually failed to show a significant difference compared to open repair in recent studies. Therefore, meticulous assessment of patient comorbidites using validated parameters is the key element for decision-making and parameters such as young age, low comorbidity profile, large aneurysm and presence of atopic renal arteries or a dominant inferior mesenteric artery should prompt a recommendation of open repair.

Mycotic Aortic Aneurysm Caused by Acinetobacter baumannii Complex

Mycotic aneurysms are uncommon, difficult to treat, and fatal. These aneurysms caused by Acinetobacter baumannii complex are not documented. We present the case of a 20-year-old female who presented with pain abdomen and vomiting with on and off episodes of fever. This woman had a history of postpartum cardiomyopathy for 12 months and chronic kidney disease for 2 months, on medical treatment. She was diagnosed with an infrarenal aortic aneurysm with iliac extension caused by A. baumannii complex and left hydronephrosis. She was successfully treated with surgery followed by long-term antibiotics. There is no documented evidence of this organism to cause mycotic aneurysm. We also discuss about the course, investigations, and management of this case.

Thrombosed Abdominal Aortic Aneurysm with Horseshoe Kidney Presenting with Acute Limb Ischemia

Acute thrombosis of an abdominal aortic aneurysm with a horseshoe kidney (HSK) is a very rare phenomenon. This anatomical anomaly poses a challenge for the surgeon which requires prompt treatment. We present a case report of an elderly man who presented with a threatened acute left leg ischemia and a pulsatile abdominal mass. Computed tomography revealed a huge fusiform infrarenal aortic aneurysm extending to the left iliac artery with thrombotic occlusion and a HSK. He underwent emergency transabdominal laparotomy and aneurysectomy with inlay bifurcated graft repair. The renal isthmus was preserved and left accessory renal artery was reimplanted onto the graft. Postoperatively, bilateral lower limb was viable and kidney function was normal. He was discharged well. Open surgery remains the gold standard in treating such a complex case promptly.

A Rare Case of Abdominal Aortic Aneurysm with Ureteral Compression

Abstract Introduction: In this report, we present a rare case of aortic aneurysm with associated left ureter obstruction and consequent hydronephrosis. Case presentation: A 62-year-old man was admitted for epigastric and periumbilical pain, extended in the spine, and anuria. As for associated diseases, he presented arterial hypertension stage II/III, chronic ischemic cardiomyopathy, acidosis, hyperpotassemia, spondylosis with radiculopathy, acute renal failure, renal lithiasis, and eating difficulties. After performing a CT scan, the patient was diagnosed with giant abdominal infrarenal aortic aneurysm with ureter compression, and retroperitoneal rupture with common and internal iliac arteries occlusion. We performed a xifo-pubian laparotomy with endoaneurysmorrhaphy and aortoiliac bilateral bypass using silver Dacron vascular prosthesis (16 × 8 mm in diameter). Douglas drainage was necessary, ending with laparoraphy. The patient presented a favorable postoperative evolution. Conclusion: Open surgery remains the gold standard method of treatment for large aortic aneurysms, given the inability of endovascular procedures to solve problems caused by compression.

Late Rupture of a Thrombosed Aortic Abdominal Aneurysm – a Case Report

Abstract Introduction: Severe back pain caused by a thrombosed and ruptured aortic abdominal aneurysm can imitate a lumbar disc herniation. Case presentation: We present the case of a 72-year-old diabetic patient with chronic atrial fibrillation, who had been experiencing high-intensity low back pain and claudication in the last year prior to his presentation. After experiencing a minor trauma, a lumbar MRI examination was performed, which revealed a retroperitoneal tumoral mass compressing and eroding the L2–L4 vertebral bodies. Computed tomography angiography showed an infrarenal aortic aneurysm (3.374 × 3.765 cm) which appeared to have ruptured and thrombosed. The question arising was when did the rupture occur, how massive was the damage, and how suitable for reconstruction was the aortic wall below the origin of the renal arteries. An open repair was scheduled and performed. The intraoperative finding was ruptured aneurysm of the thrombosed infra-abdominal aorta. The thrombosis extended along the common iliac and external iliac branches. We performed an aortobifemoral bypass using a 16 × 8 mm Dacron graft, clamping the aorta above the origin of the renal arteries. Conclusion: The unintentional diagnosis, due to a minor fall, was overall a fortunate event for this patient. Aortic aneurysms may present with lumbar pain that can be mistakenly interpreted as a spinal issue.

Complex Endovascular Repair Is Associated With Decreased Morbidity Compared to Complex Open Repair in Patients With a Prior Infrarenal Aortic Aneurysm Repair

After repair of an infrarenal aortic aneurysm, patients often require further operative management. In some centers, patients are preferentially treated with complex open repair including supraceliac or suprarenal clamping, whereas others prefer a complex endovascular repair. However, the optimal approach is unclear. This study aims to compare outcomes between complex open and endovascular procedures among patients with a prior infrarenal aortic aneurysm repair.

Open Repair of a Coxiella Burnetii-associated Abdominal Aortic Endovascular Stent Graft Infection With a Cryopreserved Allograft Using Visceral Artery Pump Perfusion

Chronic Q fever with vascular involvement is difficult to diagnose given its nonspecific symptoms. We add to the current literature by presenting a case of the surgical management of chronic Q fever with the use of selective visceral artery pump perfusion, in a 68-year-old female who lived in rural Southern California. She had frequent animal exposure and previously had an endovascular repair of her infrarenal aortic aneurysm likely from undiagnosed Q fever.

A Comparison of Computed Tomography Angiography and Colour Duplex Ultrasound Surveillance Post Infrarenal Endovascular Aortic Aneurysm Repair: Financial Implications and Impact of Different International Surveillance Guidelines

Use of colour duplex ultrasound (CDUS) and computed tomography angiography (CTA) for infrarenal endovascular aortic aneurysm repair (EVAR) surveillance differs in internationally published guidelines. This study aimed firstly to compare CDUS detection of significant sac abnormalities with CTA. Secondly, a sensitivity analysis was conducted to compare financial estimates of the, predominantly CDUS based, local and Society of Vascular Surgery (SVS) protocols, the risk stratified European Society of Vascular Surgery (ESVS) protocol, and the CTA based National Institute of Health and Care Excellence (NICE) protocol.

Long-term Anticoagulation Is Associated With Type II Endoleaks and Failure of Sac Regression After Endovascular Aneurysm Repair

Within the context of endovascular aortic repair (EVAR), the role of antiplatelet and anticoagulation therapy on endoleak development and subsequent reintervention is unclear with conflicting data in the literature. The hypothesis of this study is that chronic anticoagulation is associated with persistent endoleak and failure of sac regression in patients undergoing endoluminal repair of intact infrarenal aortic aneurysms.

The Reversed STABILISE Technique

A 64 year old man presented with acute abdominal and chest pain. (A) Computed tomography angiography showed an 84 mm infrarenal aortic aneurysm with retrograde aortic dissection arising from the aneurysm (blue arrow, entry tear) to the middle of the thoracic aorta (red arrows, dissection limits). Owing to persistent abdominal pain, he underwent endovascular aortic repair using an infrarenal bifurcated stent graft (WL Gore, Flagstaff, AZ, USA), followed by bare stenting of the upper abdominal and descending aorta (Cook Medical, Bloomington, IN, USA). Both grafts were expanded as per the STABILISE technique, allowing complete exclusion of the aneurysm and dissection (B).