Outcomes Of Endovascular Aneurysm Repair In Patients Research Articles

Systematic Review and Meta-Analysis of the Effect of Anticoagulation on Outcomes After Endovascular Aneurysm Repair.

Our objective was to investigate whether patients who receive anticoagulation therapy have different outcomes after endovascular aneurysm repair (EVAR) from those who do not. We conducted a systematic review of studies that compared outcomes of EVAR in patients who were on therapeutic anticoagulation vs those who were not. We developed and reported the review in accordance with the PRISMA guidelines with a registered protocol (CRD42022375894). The Ovid interface was used to search Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), and Cochrane Central Register of Controlled Trials (CENTRAL) up to November 2022. The quality of studies was assessed with the Newcastle-Ottawa Scale (NOS) (maximum score=9), and the evidence was appraised with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. The hazard ratio (HR) and 95% confidence interval (CI) was the effect estimate in time-to-event meta-analyses, calculated using the inverse-variance statistical method and random-effects models. Sixteen studies qualified for inclusion reporting a total of 35 739 individuals. Anticoagulated patients had a statistically significantly higher hazard of death (HR=1.93, 95% CI=1.03-3.63), endoleak (HR=2.13, 95% CI=1.55-2.93), reintervention (HR=1.79, 95% CI=1.27-2.52), and aneurysm sac expansion (HR=2.72, 95% CI=1.57-4.72) than patients not receiving anticoagulation therapy. The median score on the NOS was 7 (range=4-9). The certainty of evidence was very low for mortality and reintervention and low for endoleak and sac expansion. Anticoagulation is a poor prognostic factor after standard EVAR and should be considered in decision-making, consent processes, and surveillance strategies. The number of individuals who take anticoagulation treatment has been rapidly increasing over the recent years. We aimed to investigate the effect of such treatment on outcomes after endovascular aneurysm repair (EVAR). Anticoagulated patients were found to have increased mortality, endoleak, and reintervention rates after EVAR compared to their non-anticoagulated counterparts. Anticoagulation therapy has a prognostic role in EVAR and should be considered in decision making and EVAR surveillance. Anticoagulated patients need to be informed of the higher failure rates of EVAR, and intensified surveillance strategies may need to be implemented in this patient cohort.

Prognostic significance of large diameter proximal aortic neck in endovascular aneurysm repair.

Background: Adverse morphological features of the proximal aortic neck have been identified as culprits for late failure after endovascular aneurysm repair (EVAR). Our objective was to investigate the prognostic role of wide proximal aortic neck in EVAR. Methods: We conducted a review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies comparing outcomes of EVAR in patients with large versus small proximal aortic neck. A meta-analysis of time-to-event data was performed with the inverse-variance method and the results were reported as summary hazard ratio (HR) and 95% CI. We applied random-effects models of meta-analysis. Results: We identified 9 observational studies reporting on a total of 7,682 patients (1,961 with large diameter and 5,721 with small diameter neck). The hazard of death (HR 1.57, 95% CI 1.23-2.01; P=0.0003), aneurysm-related reintervention (HR 2.06, 95% CI 1.23-3.45; P=0.006), type Ia endoleak (HR 6.69, 95% CI 4.39-10.20; P<0.001), sac expansion (HR 10.07, 95% CI 1.80-56.53; P=0.009), aneurysm rupture (HR 2.96, 95% CI 2.00-4.38; P<0.0001), and neck-related adverse events (HR 10.33, 95% CI 4.95-21.56; P<0.0001) was higher in patients with large diameter proximal aortic neck than in those with small neck. Conclusions: Patients with a large proximal aortic neck were found to have poorer outcomes than those with small neck. This finding has implications in decision making when selecting methods for aneurysm treatment and in EVAR surveillance for aneurysm-related complications in this cohort of patients.

35 INVESTIGATION OF THE GENETIC INFLUENCES ON BIPOLAR DISORDER AND SUBCORTICAL BRAIN VOLUMES

Our objective was to investigate whether patients undergoing standard endovascular aneurysm repair (EVAR) outside the instructions for use (IFU) have worse outcomes than patients treated within IFU.We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic bibliographic sources were searched up to January 2019 using a combination of controlled vocabulary (thesaurus) and free-text terms to identify studies comparing outcomes of EVAR in patients treated outside versus within IFU. Pooled estimates of dichotomous outcomes were calculated using odds ratio (OR) or risk difference (RD) and 95% confidence interval (CI). We conducted a time-to-event data meta-analysis using the inverse-variance method and reported the results as summary hazard ratio (HR) and associated 95% CI. Random-effects methods of meta-analysis were applied. We formed meta-regression models to explore heterogeneity as a result of changes in practice over time.We identified 17 observational cohort studies published between 2011 and 2017, reporting a total of 4498 patients. The pooled prevalence of EVAR performed outside the IFU was 40% (95% CI, 33-48). Nonadherence to IFU was not associated with increased risk of perioperative mortality (RD, 0.01; 95% CI, −0.00 to 0.01; P = .23), aneurysm rupture (HR, 1.34; 95% CI, 0.30-5.93; P = .70), aneurysm-related mortality (HR, 0.88; 95% CI, 0.20-3.84; P = .86), technical failure (RD, 0.01; 95% CI, −0.03 to 0.05; P = .56), requirement for adjunctive procedures (OR, 1.48; 95% CI, 0.81-2.71; P = .20), type I endoleak (HR, 2.28; 95% CI, 0.58-8.91; P = .24), aneurysm sac expansion (HR, 0.86; 95% CI, 0.55-1.33; P = .49), or aneurysm-related reintervention (HR, 1.04; 95% CI, 0.81-1.34; P = .74). The overall mortality was significantly higher in patients treated outside the IFU (HR, 1.20; 95% CI, 1.02-1.42; P = .03). Meta-regression showed that the prevalence of EVAR performed outside the IFU has increased over time (P = .019).Standard EVAR outside the IFU was not found to have worse aneurysm-related outcomes than treatment within the IFU. Standard EVAR outside the IFU could be considered in selected patients who are deemed high risk for complex open or endovascular surgery.

Patients with large neck diameter have a higher risk of type IA endoleaks and aneurysm rupture after standard endovascular aneurysm repair

ObjectiveStandard endovascular aneurysm repair (EVAR) is the most common treatment of abdominal aortic aneurysms (AAAs). EVAR has been increasingly used in patients with hostile neck features. This study investigated the outcomes of EVAR in patients with neck diameters ≥30 mm in the prospectively maintained Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE). MethodsThis is a retrospective study comparing patients with neck diameters ≥30 mm with patients with neck diameters <30 mm. The primary end point was type IA endoleak (EL1A). Secondary end points included secondary interventions to correct EL1A, aneurysm rupture, and survival. ResultsThis study included 1257 patients (mean age, 73.1 years; 89.4% male) observed for a median 4.0 years (interquartile range, 2.7-4.8 years). A total of 97 (7.7%) patients had infrarenal neck diameters ≥30 mm and were compared with the remaining 1160 (92.3%) with neck diameters <30 mm. At baseline, there were no differences between groups regarding demographics and comorbidities other than cardiac disease, which was more frequent in the ≥30-mm neck diameter group (P = .037). There were no significant differences between the groups regarding neck length, angulation, thrombus, or calcification. Mean preoperative AAA diameter was 64.6 ± 11.3 mm in the ≥30-mm neck diameter group and 60.0 ± 11.6 mm in the <30-mm neck diameter group (P < .001). Stent graft oversizing was significantly less in the ≥30-mm neck diameter group (12.2% ± 8.9% vs 22.1% ± 11.9%; P <. 001). Five patients (5.2%) in the ≥30-mm neck diameter group and 30 (2.6%) with neck diameters <30 mm developed EL1A, yielding a 4-year freedom from EL1A of 92.4% vs 96.6%, respectively (P = .09). Oversizing was 21.8% ± 13.0% for patients developing EL1A and 21.3% ± 12.4% for the remaining cohort (P = .99). In adjusting for neck length, AAA diameter, and device oversizing, patients with neck diameter ≥30 mm were at greater risk for development of EL1A (hazard ratio, 3.0; 95% confidence interval, 1.0-9.3; P = .05). Secondary interventions due to EL1A did not differ between groups (P = .36). AAA rupture occurred in three patients with neck diameter ≥30 mm (3.1%) and in eight patients with neck diameter <30 mm (0.7%; hazard ratio, 5.1; 95% confidence interval, 1.4-19.2; P = .016); two cases were EL1A related in each group. At 4 years, overall survival was 61.6% for the ≥30-mm neck diameter group and 75.2% for the <30-mm neck diameter group (P = .009), which remained significant on correcting for sex and AAA diameter (P = .016). ConclusionsIn this study, patients with infrarenal neck diameter ≥30 mm had a threefold increased risk of EL1A and fivefold risk of aneurysm rupture after EVAR as well as worse overall survival. This may influence the choice of AAA repair and underlines the need for regular computed tomography-based imaging surveillance in this subset of patients. Furthermore, these results can serve as standards with which new, possibly improved technology, such as EndoAnchors (Medtronic, Santa Rosa, Calif), can be compared.

Long-term outcomes of standard endovascular aneurysm repair in patients with severe neck angulation

ObjectiveSevere neck angulation is associated with complications after endovascular aneurysm repair (EVAR). Newer endografts may overcome this limitation, but the literature lacks long-term results. We studied the long-term outcomes of EVAR in patients with severe neck angulation. MethodsA retrospective case-control study of a prospective multicenter database was performed. All measurements were made with dedicated software with center lumen line reconstruction. A study group including patients with neck length >15 mm, infrarenal angle (β) >75 degrees or suprarenal angle (α) >60 degrees, and neck length 10 to 15 mm with β >60 degrees or α >45 degrees was compared with a control group matched for demographics and other morphologic neck features. The primary end point was type IA endoleak (EL1A). Secondary end points were freedom from neck-related secondary interventions, primary clinical success, and overall survival. ResultsForty-five patients were included in the angulated neck group and compared with 65 matched patients. Median follow-up was 7.4 years (interquartile range, 4.8-8.5 years). In the angulated neck group, mean α was 51.4 degrees (±21.1 degrees) and the mean β was 80.8 degrees (±15.6 degrees); in the nonangulated group, these were 17.9 degrees (±17.0 degrees) and 35.4 degrees (±20.0 degrees), respectively. At 7 years, five patients in the angulated neck group and two nonangulated patients developed EL1A, yielding a freedom from EL1A of 86.1% (n = 14; standard error [SE], 0.069) and 96.6% (n = 34; SE, 0.023), respectively (P = .056). After exclusion of a patient who developed an EL1A secondary to an endograft infection, this difference was significant: 86.1% (n = 14; SE, 0.069) in the angulated neck group and 98.2% (n = 34; SE, 0.018) in the nonangulated group (P = .016). At 7 years, freedom from neck-related secondary interventions was 91.7% (n = 14; SE, 0.059) and 91.6% (n = 29; SE, 0.029), respectively. The 7-year primary clinical success estimates were 41.2% (n = 11; SE, 0.085) and 56.6% (n = 20; SE, 0.072) for the angulated neck and nonangulated groups, respectively (P = .12). The 7-year survival rates were 44.3% (n = 18; SE, 0.076) vs 66.7% (n = 42; SE, 0.059) for the angulated neck and nonangulated groups, respectively (P = .25). Device integrity failure was not observed. ConclusionsDespite satisfactory results early and in the midterm, a higher rate of EL1A was identified among patients with severely angulated necks in the long term. However, mortality was not affected by this difference. These findings suggest that EVAR should be used judiciously in patients with extreme angulation of the proximal neck and highlight the need for close follow-up of EVAR, especially in the long term and in patients treated outside instructions for use.

Successful Open Surgery for Recurrent Pseudo-aneurysm after Endovascular Aneurysm Repair in a Patient with Behçet’s Disease

Abdominal aortic aneurysm (AAA) is a life-threatening complication in patients with Behçet’s disease. Recently, endovascular aneurysm repair (EVAR) has been reported with acceptable short-term outcomes. However, we report a case in which open surgery was required for a recurrent pseudo-aneurysm after EVAR. A 54-year-old man with Behçet’s disease was diagnosed with a pseudo-aneurysm at the proximal margin of a previously inserted stent graft for AAA. We performed open surgery for removal of the stent graft and reconstruction of the left accessory renal artery. Long-term outcomes of EVAR in patients with Behçet’s disease are not necessarily acceptable.

Outcome of elective endovascular abdominal aortic aneurysm repair in octogenarians and nonagenarians

Compared to open repair of abdominal aortic aneurysms (AAA), endovascular aneurysm repair (EVAR) is associated with decreased perioperative morbidity and mortality. This study sought to examine the outcomes of EVAR in patients >or=80 years of age. This was a retrospective review from a prospectively maintained computerized database. A total of 322 patients aged >or=80 underwent elective EVAR from January 1997 to November 2007. Mean age was 84 years +/- 3.4 years (range, 80-95 years), and 78.5% were male. Mean aneurysm size was 62 mm +/- 12 mm (range, 39-110 mm). Mean procedural blood loss was 350 mL (range, 50-2700 mL), and 13.9% required intraoperative transfusion. Mean length of postoperative stay was 2.46 days (median, 1 day; range, 1-42 days), with 54.3% of patients discharged on the first postoperative day. There were 25 (7.8%) perioperative major adverse events. The most common were categorized as device-related (6), cardiac (4), gastrointestinal (4), and bleeding/hematoma (3). The perioperative 30-day mortality rate was 3.1% (10 of 322). Mean follow-up was 25.7 months (range, 1-110 months). Overall, 47 patients (14.6%) required secondary intervention, 7 patients (2.2%) underwent conversion to open repair, and 4 patients (1.2%) died from AAA rupture. Endoleaks occurred in 95 patients (29.4%), with 20 type I, 48 type II, and 27 of indeterminate type; of these, 10 patients with type I endoleaks underwent secondary intervention. Freedom from all-cause mortality at 1 year was 84.3% and at 5 years was 27.4%. Freedom from aneurysm-related mortality at 5 years was 92.9%. EVAR in octogenarians is associated with high procedural success and low perioperative morbidity and mortality. The midterm results of this study support the use of EVAR in this patient population. Further studies are needed to predict short-term and long-term mortality risk, and treatment for other causes of death.