Outcomes Of Endovascular Aneurysm Repair Research Articles

Single-center Study Comparing Short and Mid-Term Results of EVAR in Old and Young Populations.

ObjectiveThe purpose of this study was to compare the operative mortality rate and outcomes of endovascular aneurysm repair (EVAR) between young and geriatric people in a single center.MethodsEighty-five patients with abdominal aortic aneurysms who underwent EVAR between January 2012 and September 2016 were included. Outcomes were compared between two groups: the young (aged < 65 years) and the geriatric (aged ≥ 65 years). The primary study outcome was technical success; the secondary endpoints were mortality and secondary interventions. The mean follow-up time was 36 months (3-60 months).ResultsThe study included 72 males and 13 females with a mean age of 71.08±8.6 years (range 49-85 years). Of the 85 patients analyzed, 18 (21.2%) were under 65 years old and 67 patients (78.8%) were over 65 years old. There was no statistically significant correlation between chronic disease and age. We found no statistically significant difference between aneurysm diameter, neck angle, neck length, or right and left iliac angles. The secondary intervention rate was 7% (six patients). The conversion to open surgery was necessary for only one patient and only three deaths were reported (3.5%). There was no statistically significant difference in the mortality and reintervention rates between the age groups. The three deaths occurred only in the geriatric group and two died secondary to rupture. Kidney failure was observed in three patients in the geriatric group (4.5%).ConclusionOur single-center experience shows that EVAR can be used safely in both young and geriatric patients.

Long-Term Results after Endovascular Aneurysm Repair (EVAR) with the Zenith Stent Graft

The device-specific long-term results of endovascular aneurysm repair (EVAR) is limited as most of the studies are large multicentre trials reporting the combined results of different devices. The main concern regarding endovascular approach for abdominal aortic aneurysm (AAA) has been the high complication and re-intervention rates after EVAR compared to open repair (OR). This concern has led to a recommendation of lifelong surveillance. However, almost 80% of EVAR patients undergo re-intervention-free surveillance. Therefore, the annual monitoring of all EVAR patients is, therefore, unnecessary. The fatal AAA rupture after EVAR is rare, but an annual rupture risk of 0.49% remains despite the systematic follow-up. The most common cause of death after EVAR is the cardiac event. The overall survival among these patients is poor as multiple comorbidities diminish the life expectancy. Approximately only half of the EVAR-treated patients reach the 5-year followup. At the same time, every tenth patient lives up to 16 years and over thus highlighting the importance of durability of the stent grafts. The basic features of the Cook Zenith stent graft haven´t changed much over the years. Available long-term data can, therefore, be used in decision making when considering AAA treatment with Zenith device and discussing the treatment options with the patient.

Midterm Single-Center Results of Endovascular Aneurysm Repair With Additional EndoAnchors

Purpose: To review midterm clinical outcomes of EndoAnchor placement during or after endovascular aneurysm repair (EVAR) or chimney EVAR (ch-EVAR). Materials and Methods: A retrospective analysis was conducted of 51 consecutive patients [median age 75 years; 38 men] who underwent EVAR/ch-EVAR with EndoAnchor placement between June 2010 and December 2016 to prevent seal failures (31, 61%) or to treat type Ia endoleak and/or migration (20, 39%). Median aortic neck diameter was 27.7 mm and median neck length was 9.0 mm. Thirty-three (65%) had a conical neck; 48 (94%) had at least 1 hostile neck characteristic. Thirty-two (63%) patients had severe comorbidities (ASA score ⩾III). Eight patients had a single ch-EVAR procedure. Baseline patient characteristics, anatomic variables, procedure details, early and late complications, reinterventions, and aneurysm-related and all-cause mortality rates were recorded. Follow-up imaging was performed with computed tomography angiography (CTA) or duplex ultrasonography. Results: Median procedure time was 100 minutes; a median of 6 EndoAnchors were implanted. There were 10 (10%) residual type Ia endoleaks at the end of the procedure; 9 had resolved by the first postoperative CTA. One residual and 2 new type Ia endoleaks were identified at the first postoperative imaging. Median follow-up for the entire cohort was 24.0 months, during which 3 new type Ia endoleaks were identified. Five of the 6 type Ia endoleaks were treated, 1 resolved spontaneously. There was 1 endograft limb occlusion without clinical consequences, 1 chimney graft occlusion without possibilities for a reintervention, 1 rupture after type IV endoleak (a Nellix device was successfully deployed within the main device), and 1 complete graft explantation for infection. There was no new-onset hemodialysis. Kaplan-Meier estimates of freedom from type Ia endoleak, proximal neck–related reinterventions, and aneurysm-related mortality at 2 years were 87.3%, 92.2%, and 94.0%, respectively. Conclusion: EndoAnchors are helpful in the endovascular treatment of unfavorable proximal aortic necks, with fair midterm results.

Results of endovascular aneurysm repair of infrarenal aorta and iliac arteries in patients with severe concomitant diseases

The objectiveof this study was to assess the efficacy and safety of endovascular aneurysm repair (EVAR) of infrarenal aorta (IA) and iliac arteries (IA) with favorable and unfavorable anatomy in the group of high-risk patients after surgery and at follow-up examinations.Material and methods. The study is based on the results of the study of 95 patients with abdominal aortic aneurysms and iliac arteries aneurysms who underwent EVAR at Healthcare «Clinical Hospital № 122 named after L.G. Sokolov» for the period from March 2008 to December 2016. RESULTS. Results of EVAR of infrarenal aorta and iliac arteries in patients with severe concomitant diseases were analyzed. The interventions were successful in 100 % of cases.Сonclusions.The study has shown that EVAR is an effective and safe method of treatment for endovascular aneurysm repair of infrarenal aorta and iliac arteries in high-risk patients. Long-term care requires abdominal aorta and iliac artery examination with the use of duplex ultrasound angioscanning and multispiral computed tomoangiography to identify specific complications.

Fenestrated and branched endovascular aneurysm repair outcomes for type II and III thoracoabdominal aortic aneurysm

Fenestrated and branched endovascular aneurysm repair outcomes for type II and III thoracoabdominal aortic aneurysm

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.

Abdominal Aortic Aneurysm Anatomic Severity Grading Score: Identifying Anatomic Attributes That Best Predict Endovascular Aneurysm Repair Outcomes

The Society for Vascular Surgery anatomic severity grading (ASG) score is a classification system for abdominal aortic aneurysms (AAAs) stratifying candidates for endovascular aneurysm repair (EVAR). Our objective was to determine the predictive capability of total ASG score, subscores, and individual attributes for implant-related complications, endoleak, and reinterventions. Patients who underwent EVAR between 2009 and 2012 with M2S (West Lebanon, NH) three-dimensional computed tomography reconstructions were retrospectively reviewed. ASG scores were calculated from morphologic measurements by two blinded observers. Twenty-five attributes compose subscores for aortic neck, AAA, iliac arteries, and total ASG score. We identified 100 patients with mean ASG score of 18.6 ± 4.5 (range, 7.5-29). Mean AAA diameter was 54 ± 10 mm. Mean follow-up was 3.93 ± 2.5 years. Interobserver variability was determined using intraclass correlation coefficient, reflecting degree of correlation and agreement. Inter-rater agreement was good to excellent for total ASG score calculations (intraclass correlation coefficient, 0.86; 95% confidence interval, 0.70-0.92). Area under the receiver operating curve (AUROC) analysis was performed to study outcomes. Total ASG score was not a significant predictor of any outcomes. A neck subscore of ≥3 was highly predictive for type IA endoleak (AUROC, 0.82; P = .005; 95% confidence interval, 0.71-0.93) and aneurysm enlargement (AUROC, 0.71; P = .003). AAA tortuosity predicted 30-day reinterventions (AUROC, 0.84; P = .02). Iliac calcification predicted 30-day reinterventions (AUROC, 0.84; P = .021) and 30-day implant complications (AUROC, 0.8; P =. 027). The AAA and iliac subscores did not correlate with any significant outcomes. Total ASG score consists of several subscores and attributes, not all of which predict outcomes. The aortic neck subscore was predictive of type IA endoleak and sac enlargement; AAA tortuosity and iliac calcification predicted 30-day reinterventions or 30-day implant complications. This study suggests that total ASG score can be simplified to reflect attributes most predictive of EVAR outcomes.

Outcomes of familial abdominal aortic aneurysm repair in the Vascular Quality Initiative

ObjectiveRecent investigations have reported increased rates of aneurysm-related complications after endovascular aneurysm repair (EVAR) in familial abdominal aortic aneurysm (fAAA) patients. The purpose of this study was to evaluate the outcomes of open aortic repair (OAR) and EVAR in sporadic AAA (spAAA) and fAAA patients in the Society for Vascular Surgery Vascular Quality Initiative. MethodsThis was a retrospective review of all AAA repairs in the Vascular Quality Initiative from 2003 to 2017. Patients' data were summarized, and standard statistical analysis was performed. Patients with known genetic syndromes and centers with long-term follow-up of <50% of patients were excluded. ResultsFrom 2003 to 2017, there were 1997 fAAA patients compared with 18,185 spAAA patients undergoing OAR and EVAR during the same study period. Compared with their spAAA counterparts, fAAA patients were younger (P < .001), were more likely to be living at home before surgery (P = .008), and demonstrated a lower incidence of coronary artery disease (P = .001) and hypertension (P = .039). Rates of smoking and end-stage renal disease did not differ between groups. However, fAAA patients were more likely to have aneurysmal degeneration of their iliac arteries (P < .001) and to undergo OAR (P < .001). When analyzing patients undergoing OAR, we found that fAAA patients were more likely to require concomitant renal bypass surgery (P = .012) but were extubated sooner (P = .005), received fewer blood transfusions (P < .001), and had a shorter length of stay (P = .018). Although individual complication rates did not differ between fAAA and spAAA groups after OAR, a composite end point of all early postoperative complications was decreased in fAAA patients (P = .020). When comparing fAAA and spAAA patients who underwent EVAR, we found a greater incidence of early lumbar branch endoleaks (type II) in fAAA patients; however, the rate of proximal type IA endoleaks (P = .279) and the rate of late reintervention for sac growth (P = .786), any endoleak (P = .439), or rupture (P = .649) did not differ between the groups. Whereas spAAA patients undergoing EVAR required longer postoperative intensive care unit stays (P < .001) and had a greater incidence of blood transfusions (P < .001), fAAA and spAAA patients had similar rates of postoperative complications (P = .510), 30-day mortality (P = .177), and long-term mortality (P = .259). ConclusionsThis study shows that patients with a familial form of AAA do not have increased morbidity or mortality after AAA repair. Our findings suggest that EVAR and OAR are both safe and effective for fAAA patients. Further studies with longer follow-up are needed to best care for this unique cohort of patients.

Endovascular treatment of primary mycotic aortic aneurysms: a 7-year single-center experience.

ObjectiveThis study was performed to assess the efficacy and outcome of endovascular aneurysm repair (EVAR) for treatment of primary mycotic aortic aneurysms (PMAAs).MethodsFourteen consecutive patients who presented with PMAA from April 2010 to July 2017 were retrospectively reviewed. Preoperative, intraoperative, and postoperative clinical data were recorded, and late infection-related complications and long-term survival were assessed.ResultsThe aneurysms were located in the abdominal aorta in 10 patients and in the left common iliac artery in 4 patients. Positive microbial cultures were found in 12 patients, including Salmonella species in 11 and Streptococcus in 1. The remaining two patients had negative culture results. Ten patients received preoperative antibiotics before elective EVAR for 7 ± 9 days after admission. Four patients who underwent emergent EVAR due to ruptured aneurysms were given their first dose of antibiotics before EVAR. Three patients underwent surgical drainage, and six underwent percutaneous drainage within 30 days after EVAR. No death occurred within 30 days of the initial procedure. The mean follow-up was 34.8 (range, 3–84 months). One patient underwent re-intervention to resolve obstruction of the iliac/femoral artery 5 months postoperatively. Relapse of infection occurred in six patients (42.8%) during follow-up; infection-related death occurred in three of these patients. The other patients recovered with either conversion to open radical surgery or medical therapy. The actuarial 7-year survival after EVAR was 75.7%.ConclusionsEVAR and aggressive antibiotic therapy might be suitable for PMAAs. Favorable results may be typical for infection caused by Salmonella.

A better way in: improving patient outcomes in endovascular aneurysm repair by using percutaneous access

A better way in: improving patient outcomes in endovascular aneurysm repair by using percutaneous access

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.

Trends of 30-day mortality and morbidities in endovascular repair of intact abdominal aortic aneurysm during the last decade

ObjectiveSignificant research efforts have been made to improve the safety and efficacy of endovascular aneurysm repair (EVAR) in treating abdominal aortic aneurysm. This study aimed to examine the trends of perioperative outcomes of EVAR in the recent decade using a national validated database. MethodsPatients who underwent EVAR for intact abdominal aortic aneurysm between 2006 and 2015 were identified from the National Surgical Quality Improvement Program and divided into early (2006-2010) and late (2011-2015) periods. The primary outcome of the study was 30-day mortality. Secondary outcomes included operative time, length of hospital stay, and 30-day major complications (renal, cardiopulmonary, and wound infection). ResultsA total of 30,076 patients were identified, with 11,539 in the early period and 18,537 in the late period. The 30-day mortality was kept at a low level in both periods (1.2% vs 1.2%; P = .98), whereas both the mean operation time (155.5 ± 72.6 minutes vs 141.9 ± 73.7 minutes; P < .001) and length of hospital stay (3.24 ± 5.32 days vs 2.81 ± 4.30 days; P < .001) were decreased in the late period. The 30-day major complication rate was reduced by 19.6% (5.1% vs 4.1%; P < .0001), with decreased renal failure (1.4% vs 1.0%; P = .003), cardiopulmonary complications (2.2% vs 1.7%; P = .006), and wound complications (2.5% vs 1.8%; P < .001). All the decreasing trends of mortality, any 30-day complication, and each type of major complication were statistically significant. Being treated in the late period was independently associated with decreased 30-day major complications (odds ratio, 0.75; 95% confidence interval, 0.65-0.87; P < .001), and this effect was confirmed in the propensity score-matched cohort (odds ratio, 0.76; 95% confidence interval, 0.66-0.90; P < .001). ConclusionsAlthough the 30-day mortality remains similar, postoperative complications in EVAR have decreased significantly during the recent decade. The continuous improvement in endograft technology and surgical skills has resulted in decreased operative time, marked reduction in surgical complications, and shorter hospital length of stay after endovascular repair.

Midterm Outcomes of Endovascular Aortic Aneurysm Repair with Carbon Dioxide–Guided Angiography

Although iodinated contrast (IC) agents are commonly used in endovascular aneurysm repair (EVAR), perioperative use in patients with renal dysfunction or IC allergies is avoided. Carbon dioxide (CO2)-guided angiography is a promising alternative. We aimed to evaluate short-term and midterm outcomes of EVAR using CO2-guided angiography. Three hundred eighty-one patients who underwent EVAR from January 2012 to September 2016 were retrospectively reviewed and divided into an IC-EVAR group (n=351) and CO2-EVAR group (n=30). Subjects in the CO2-EVAR group had severe renal dysfunction (n=27) and IC allergy (n=4). Intraoperative, postoperative, and follow-up variables were compared. Compared with the IC-EVAR group, preoperative serum creatinine level was significantly higher (2.0 vs. 0.92mg/dL, P<0.0001) and mean IC dose was significantly lower (18 vs. 55mL,P<0.0001) in the CO2-EVAR group. The fluoroscopy time, operative time, number of stent grafts placed, and technical success rates of the groups were similar; no type I and/or type III endoleaks were detected on completion angiography. There was no acute kidney injury and one case of intestinal necrosis in the CO2-EVAR group, potentially due to cholesterol embolism. Postoperative endoleak, enlargement of aneurysms, survival, freedom from secondary intervention, and renal function change up to 3months, postoperatively, were similar between the groups. CO2-EVAR is technically feasible and exhibits prominent renal protection. However, consideration of the aortic lumen status remains an important challenge.

Endovascular Aneurysm Repair–First Strategy for Ruptured Aneurysm Focuses on Fitzgerald Classification and Vein Thrombosis

Recent study have demonstrated the good results of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (RAAAs). We report on the results of our EVAR-first strategy for RAAAs focuses on Fitzgerald (F) classification and vein thrombosis. From 2011 to 2017, 31 patients with RAAA underwent EVAR at our hospital. We compared F-1 patients (group A) with F-2 to F-4 patients with obvious retroperitoneal hematoma (group B). The baseline characteristics in group A (n=9) and group B (n=22) were similar. In group B, there were 8 cases of F-2, 10 cases of F-3, and 4 cases of F-4. Of the 22 cases in group B, 16 (73%) cases involved preoperative shock. Operation time was not significantly different (group A: 147min and group B: 131min, P=0.48). The total mortality rate of group A and group B combined was 77.4%. The 30-day mortality was 0% for group A and 23.8% for group B, in which there were 2 F-4 cases and 3 F-3 cases. In group B, hematoma-related complications developed in 6 cases (deep vein thrombosis: 4 cases, abdominal compartment syndrome: 1 case, and hematoma infection: 1 case), and 1 case with deep vein thrombosis developed a pulmonary embolism that resulted in cardiac arrest. The 3-year survival rate was significantly higher for group A (100% vs. 52.3%, P=0.016), but the freedom from aortic death rate was not significantly different (100% vs. 66.7%, P=0.056). Using EVAR for RAAA is a valid strategy. Certain complications that are associated with peritoneal hematoma, especially venous thrombosis, should receive particular attention.

Initial Clinical Experience Using the Low-Profile Altura Endograft System With Double D-Shaped Proximal Stents for Endovascular Aneurysm Repair

Purpose: To report the initial clinical results of endovascular aneurysm repair (EVAR) using the low-profile (14-F) Altura Endograft System, which features a double “D-shaped” stent design with suprarenal fixation and modular iliac components that are deployed from distal to proximal. Methods: From 2011 to 2015, 90 patients (mean age 72.8±8.3 years; 79 men) with abdominal aortic aneurysm (AAA; mean diameter 53.8±5.7 mm) were treated at 10 clinical sites in 2 prospective, controlled clinical studies using the Altura endograft. Outcomes evaluated included mortality, major adverse events (MAEs: all-cause death, stroke, paraplegia, myocardial infarction, respiratory failure, bowel ischemia, and blood loss ≥1000 mL), and clinical success (freedom from procedure-related death, type I/III endoleak, migration, thrombosis, and reintervention). Results: Endografts were successfully implanted in 89 (99%) patients; the single failure was due to delivery system malfunction before insertion in the early-generation device. One (1%) patient died and 4 patients underwent reinterventions (1 type I endoleak, 2 iliac limb stenoses, and 1 endograft occlusion) within the first 30 days. During a median follow-up of 12.5 months (range 11.5–50.9), there were no aneurysm ruptures, surgical conversions, or AAA-related deaths. The cumulative MAE rates were 3% (3/89) at 6 months and 7% (6/89) at 1 year. Two patients underwent coil embolization of type II endoleaks at 6.5 months and 2.2 years, respectively. Clinical success was 94% (84/89) at 30 days, 98% (85/87) at 6 months, and 99% (82/83) at 1 year. Conclusion: Early results suggest that properly selected AAA patients can be safely treated using the Altura Endograft System with favorable midterm outcome. Thus, further clinical investigation is warranted to evaluate the role of this device in the treatment of AAA.

Early experiences of endovascular aneurysm repair for ruptured abdominal aortic aneurysms.

PurposeThe use of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (r-AAA) is steadily increasing. We report early experiences of EVAR for r-AAA performed in two tertiary referral centers in Korea.MethodsWe retrospectively reviewed r-AAA patients treated by EVAR from May 2013 to December 2017. An EVAR-first strategy for r-AAA was adopted whenever feasible. The demographic information, anatomic characteristics, operative details, postoperative complications with special attention to abdominal compartment syndrome (ACS), and 30-day mortality were collected and analyzed.ResultsWe identified 13 patients who underwent EVAR for r-AAA. Mean age was 74.2 years and mean AAA size was 74.2 mm. Two patients underwent cardiopulmonary resuscitation at initial presentation. Bifurcated stent grafts were used in 12 out of 13 cases and physician-modified endografts with fenestrated/chimney techniques were performed in 2 cases with short neck. Successful stent graft deployment was achieved in all cases. Three patients were suspected of having ACS and 2 of them underwent laparotomy for decompression. The 30-day mortality was 7.7% (1 of 13), the only mortality being a patient that refused decompressive laparotomy for suspected ACS.ConclusionDespite the small numbers, the outcomes of EVAR for treatment of r-AAA were very promising, even in selected cases with unfavorable anatomy. These outcomes were achieved by a dedicated and well-trained team approach, and by use of high-end angiographic technology. Finally, ACS after EVAR is not uncommon, and requires a high index of suspicion as well as liberal use of decompressive surgery.

Patients Older Than 80 Years Can Reach Their Normal Life Expectancy After Abdominal Aortic Aneurysm Repair: A Comparison Between Endovascular Aneurysm Repair and Open Surgery

Purpose: To investigate the long-term outcomes of endovascular aneurysm repair (EVAR) and open surgical repair (OSR) of infrarenal abdominal aortic aneurysm in octogenarian patients and to compare them with the overall expected survival based on a sex- and age-matched German population. Methods: A total of 177 patients (median age 82 years; 149 men) ≥80 years old (range 80–92) who underwent primary elective repair of an infrarenal aortic aneurysm (≥5 cm) between 1998 and 2015 were identified in a database search. Two groups of patients were formed based on the type of procedure: 131 EVAR patients (median age 83 years; 114 men) and 46 OSR patients (median age 82 years; 35 men). Results: The median follow-up was 5 years for the OSR group and 4.5 years for the EVAR group. Kaplan-Meier analysis showed no significant difference in survival between the EVAR and OSR groups at 78 months. The observed survival of all study patients was not statistically different from the expected survival of a sex- and age-matched German population, which was true separately for women and men. Conclusion: The patients in this study seemed to reach normal life expectancy in comparison to the age- and sex-matched general population with a similar cumulative survival in both study groups over 5 years of follow-up.

Invited commentary

This study is a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) vascular module database. The authors compared the 30-day reintervention and mortality rates after endovascular aneurysm repair (EVAR) and open repair for 5877 abdominal aortic aneurysms (AAAs). Surprisingly, the 30-day reintervention rate was higher after open repair than after EVAR. Also, reintervention was associated with a 12 times higher mortality after either procedure. There have been a number of large-scale randomized controlled trials comparing open repair vs EVAR, but most are outdated and have not investigated the 30-day reintervention rate and its impact on mortality; therefore, this study provides valuable and updated information. In this study, even though the authors have selected only infrarenal AAA and have not included juxtarenal and pararenal AAAs, and although the open group patients were younger than the EVAR group, it is likely that the open group consisted of AAAs including those with shorter proximal neck, concomitant aortoiliac occlusive disease, shaggy aorta, and angulated anatomy, all of which make EVAR difficult. Because of this selection bias, it is likely that the open group consisted of more difficult AAAs, and this probably affected the poor outcome in the open group. Having said that, and despite these shortcomings, I believe that this study is bright news for EVAR technology, for which confidence had somewhat been lost following publication of the long-term results of the EVAR 1 trial.1Patel R. Sweeting M.J. Powell J.T. Greenhalgh R.M. EVAR trial investigatorsEndovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomized controlled trial.Lancet. 2016; 388: 2366-2374Abstract Full Text Full Text PDF PubMed Scopus (600) Google Scholar The current study confirms that with modern devices and improved techniques, EVAR can be performed with extremely low mortality, open conversion, and early reintervention rate. On the contrary, this study showed an alarmingly high reoperation rate after open repair, even considering the aforementioned selection bias. This may be due to deterioration of open AAA repair training and performance, something that we have been concerned about since EVAR became the first-line treatment and the number of open repairs decreased dramatically. This alarming finding has been confirmed in a recent international study, and this observation appears to be real.2Budtz-Lilly J. Venermo M. Debus S. Behrendt C.A. Altreuther M. Beiles B. et al.Assessment of international outcomes of intact abdominal aortic aneurysm repair over 9 years.Eur J Vasc Endovasc Surg. 2017; 54: 13-20Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar The study also showed that reoperation was higher in patients who underwent open repair, those who had larger AAAs, and those with hypertension and chronic kidney disease. These data should be considered to further improve the care of AAAs, which is exactly the goal of the NSQIP program. In summary, although this study is retrospective and nonrandomized and suffers from selection bias, it represents modern AAA practice in the United States and shows progressively improving EVAR outcome and, on the contrary, dwindling and deteriorating open repair, something that the vascular surgeons need to take seriously. I would like to thank the NSQIP program and the authors for providing us valuable information that has pointed out what we need to do to improve the overall care of AAAs. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Early reintervention after open and endovascular abdominal aortic aneurysm repair is associated with high mortalityJournal of Vascular SurgeryVol. 67Issue 2PreviewAlthough reinterventions are generally considered more common after endovascular aneurysm repair (EVAR) than after open surgical repair (OSR), less is known about reintervention in the early postoperative period. Furthermore, there are few data regarding the impact of early reintervention on 30-day mortality. We sought to evaluate the rates and types of reintervention after abdominal aortic aneurysm (AAA) repair and the impact of reintervention on postoperative mortality. Full-Text PDF Open Archive

Recent Advances and Mid-to-Long Term Results of Endovascular Aneurysm Repair for Abdominal Aortic Aneurysms

Recent Advances and Mid-to-Long Term Results of Endovascular Aneurysm Repair for Abdominal Aortic Aneurysms

Clinical Outcomes of Endovascular Aneurysm Repair with the Kilt Technique for Abdominal Aortic Aneurysms with Hostile Aneurysm Neck Anatomy: A Korean Multicenter Retrospective Study.

We aimed to evaluate the clinical efficacy and short-term clinical outcomes of Kilt technique-based endovascular aneurysm repair (EVAR) with Seal® stent-grafts for abdominal aortic aneurysms (AAAs) with hostile neck anatomy (angle>60°). We retrospectively evaluated the pre-EVAR and follow-up computed tomography angiography findings of 24 patients (mean age 71±11years; age range 32-87years; mean follow-up 50±12months) with hostile neck AAAs treated between 2010 and 2015. Serial change in aneurysmal neck angle was calculated using a standardized protocol. Relationships between clinical variables and outcomes were evaluated using univariate and multivariate Cox analyses and mixed-model regression. In addition, the Kaplan-Meier method was used to assess the cumulative rates of survival, endoleak, and reintervention. The primary technical success rate (success within 24h after EVAR) was 100% (24/24). The survival rate was 96±8% at 1month, 6months, 1year, and 3years, and 87±18% at 5years. Endoleaks occurred in three patients. Four reinterventions were performed in three patients; no surgical revisions were required. Causes of post-EVAR mortality included intracerebral hemorrhage at 14days and rhabdomyolysis at 32months. The most remarkable change after Kilt-based EVAR was an acute decrease in the neck angle, which was observed between the pre-EVAR and first follow-up visits (at 1month) (P=0.001). Kilt-based EVAR with Seal® stent-grafts for AAAs with a severely angulated neck (angle>60°) provided high technical success, low mortality, and low complication rates during short-term follow-up.