Presence Of Endoleak Research Articles

The Enzen Trial: Analysis of EVAR Endoprosthesis Zenith and Endurant for Infrarenal Aortoiliac Aneurysms Regarding Outcomes, Endoleaks, and Reinterventions.

The main objective of this paper is to analyze the outcomes regarding endoleaks, reinterventions, and death related to aneurysm complications in patients submitted to endovascular repair (EVAR) for abdominal aortoiliac aneurysm (AAA) using Endurant II (Medtronic) and Zenith Flex (Cook) endografts. This was a prospective, consecutive cohort study of patients with AAA who underwent EVAR between January 2019 and December 2022. Two groups of patients were evaluated: Group Endurant (patients submitted to EVAR with the use of Endurant II) and Group Zenith (patients submitted to EVAR with the use of Zenith Flex). A total of 156 patients were evaluated. Group Zenith (67 patients, 42.9%) and Group Endurant (89 patients, 57.1%). The perioperative mortality was 5.1%, eight patients (six patients Group Zenith, and two patients Group Endurant, p=0.054). There were 28 patients (17.9%) submitted to urgent repair of the aneurysm (expansion or rupture), with no differences among the groups. There were 36 cases (23.1%) of later endoleak, with a higher incidence in Zenith group (23 patients, 34.3%) than Endurant group (13 patients, 14.6%, p=0.002), most of them Type II endoleak (21 patients, 13.4%). There were 12 cases of Type I endoleak, also with a higher prevalence in Zenith group (13.4%) than Endurant group (3.4%, p=0.002). Moreover, regarding limb graft occlusion (LGO), there were nine patients (5.8%), with a higher prevalence in Zenith group (9%) than Endurant group (3.4%, p=0.045). The overall survival in a Kaplan-Meier at 720 days was 82.3% in the Zenith group and 89.1% in the Endurant group, with no statistical significance among the groups (p=0.09). The freedom from reintervention rates in a Kaplan-Meier at 720 days was 82.8% in the Zenith group and 93.2% in the Endurant group (p=0.001). In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, LGO and reinterventions than patients submitted to Endurant II endografts. The linear regression analysis showed that the presence of endoleaks, type of endograft device (Zenith graft) and limb graft occlusion were related to higher reintervention rates. In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, limb graft occlusions and reinterventions than patients submitted to Endurant II endografts. The main impact and the innovation that this article provides is an opportunity to evaluate and choose the best endograft suitable for the patient with AAA during EVAR.

Endovascular repair for infra-renal aortic aneurysms with supra-renal fixation endoprosthesis: Results and outcomes.

The main objective of this paper is to evaluate the outcomes regarding endoleaks, reinterventions, and death related to aneurysm complications in patients submitted to endovascular repair (EVAR) for abdominal aortoiliac aneurysm (AAA) using Endurant II (Medtronic) and Zenith Flex (Cook) endografts. This was a prospective, consecutive cohort study of patients with AAA who underwent EVAR with the use of Endurant II stent graft and Zenith Flex endograft. A total of 156 patients submitted to EVAR were evaluated. The perioperative mortality was 5.1%, 8 patients. The median clinical follow-up period was 760 ± 80 days. There were 28 patients (17.9%) submitted to urgent repair of the aneurysm (symptomatic expansion or rupture) and 128 patients (82.1%) submitted to elective repair. There were 36 cases (23.1%) of later endoleak and most of them are Type II endoleaks (21 patients, 13.4%). There were 12 cases of Type I endoleak. Moreover, regarding limb graft occlusion (LGO), there were 9 patients (5.8%). The overall survival rate in Kaplan-Meier analysis at 720 days was 84.8% in the total cohort. The freedom from reintervention rate in Kaplan-Meier analysis at 720 days was 92.7% in the total cohort. The linear regression analysis for survival rates showed that chronic kidney disease (p = .03; hazard ratio (HR) = 2.82, CI = 1.07-4.44) was the only factor related to poorer survival rates in both univariate and multivariate analyses. The linear regression analysis showed that the presence of endoleaks (p < .001, HR = 6.69, CI = 2.26-8.48) and limb graft occlusion (p < .001, HR = 8.02, CI = 1.60-9.99) were related to reintervention in both univariate and multivariate analyses. In this present study, supra-renal fixation endograft devices were safe and efficient in treating AAA, with satisfactory results and no renal compromise. The linear regression analysis showed that the presence of endoleaks and limb graft occlusion were related to higher reintervention rates in both univariate and multivariate analyses.

Duplex Ultrasound–Only Surveillance after Endovascular Abdominal Aortic Aneurysm Repair is Associated with Favorable Long-Term Outcomes

ObjectiveLong-term data surrounding the impact of different endovascular abdominal aortic aneurysm repair (EVAR) surveillance strategies is limited. Therefore, the purpose of this study was to characterize postoperative imaging patterns, as well as to evaluate the association of duplex ultrasound surveillance after the first postoperative year with 5-year EVAR outcomes. MethodsEVAR patients (2003-2016), who survived at least 1-year without aneurysm rupture, conversion to open repair, and reintervention in the Vascular Implant Surveillance and Interventional Outcomes Network (VISION) were examined to provide all subjects ≥3-years of follow-up time. Patients were categorized into 6 cohorts after the first postoperative year: No imaging (N=953); CT/MRI-only (N=2,976); Duplex ultrasound-only (DUS; N=1,808); Combined CT/MRI+DUS with >50% being CT/MRI (N=1,937); Combined CT/MRI+DUS with >50% being DUS (N=2,253); and Mixed (CT+DUS+MRI-N=1,272). Abdominal aortic aneurysm (AAA) related re-intervention, rupture, conversion to open repair, and all-cause mortality were estimated using Kaplan-Meier analysis. Multivariable logistic regression models identified variables associated with using DUS-only imaging (vs. CT/MRI only). Cox regression models compared 5-year outcomes between patients receiving DUS-only vs. CT/MRI-only imaging. ResultsA total of 11,199 EVAR patients were examined (mean age-76±7 years; female-20%; non-elective-10%). DUS-only imaging surveillance after the first postoperative year was more likely to occur after elective repairs, as well as among older, male patients. Smaller (<6cm) preoperative AAA diameter and absence of documented concurrent iliac aneurysm was also associated with DUS-only follow-up. Additionally, no endoleak detection on index EVAR completion imaging, as well as a documented >5mm decrease in AAA sac diameter at 1-year follow-up was more common with DUS-only surveillance protocols. Post-EVAR DUS-only imaging after the first postoperative year had the lowest incidence of re-intervention, conversion to open repair, and rupture (as well as the composite reintervention/open conversion/rupture; log-rank P<.001 for all). Further, patients receiving exclusively DUS after their first postoperative year had better overall survival (log-rank P<.001). These outcome advantages that were associated with DUS-only surveillance compared with CT/MRI-only surveillance after EVAR persisted when controlling for baseline co-variates, preoperative AAA diameter, prior aortic surgery history, sac growth, and presence of endoleak (all P<.01). ConclusionsEVAR patients selected for DUS-only surveillance after the first postoperative year have excellent freedom from AAA-related reintervention, conversion to open repair, rupture and all-cause mortality. These findings remained on multivariable analysis after adjusting for baseline characteristics, endoleak status and sac diameter changes within the first year. This is the first registry-based investigation to document long-term EVAR outcomes for patients entered into a DUS-only monitoring protocol which serves to corroborate the growing evidence base that DUS may be able to supplant CT surveillance in certain subgroups. A prospective randomized multi-center trial comparing DUS versus CT-based imaging after EVAR is needed to validate these findings which may serve to change current practice guidelines, as well as industry and regulatory stakeholder requirements.

Low-profile versus standard-profile stent grafts in the treatment of abdominal aortic aneurysm: a case-matched study.

Endovascular aortic repair (EVAR) is nowadays a widespread method of managing abdominal aortic aneurysm (AAA). Low-profile stent grafts (LPSGs) enable treatment of patients with complex and anatomically challenging aneurysms, and facilitate a percutaneous and thus less invasive procedure. To assess the outcomes of EVAR with low-profile versus standard-profile stent grafts (SPSGs). Thirty-one patients with abdominal aortic aneurysms (AAA) were treated by endovascular aortic repair (EVAR) using LPSGs. The control group of patients treated with SPSGs was matched with MedCalc software. The clinical records and the preoperative and follow-up computed tomography angiography of patients who underwent endovascular treatment of AAA were included in this study. Patients in the LPSG group had significantly more often low access vessel diameter (< 6 mm) compared to the SPSG group (38.7% vs. 6.7%, p = 0.003). In 1-year follow-up, there was no rupture, no infection, no conversion to open repair and no aneurysm-related death. Five secondary interventions were necessary in the SPSG group and only 1 in the LPSG group (p = 0.09). Type of stent graft was not a risk factor of perioperative complications, presence of endoleak or reintervention (p > 0.05). Risk factors for perioperative complications were COPD and conical neck (OR = 6.3, 95% CI: 1.5-25, p = 0.01 and OR = 6.2, 95% CI: 1-39.76, p = 0.04). The risk factor for endoleak was lower maximal aneurysm diameter. The risk factor for reintervention was proximal neck diameter (OR = 0.77, 95% CI: 0.-0.97, p = 0.03). Our study showed that use of LPSGs is a safe and viable method for patients with narrow access vessels who are not eligible for standard-profile systems.

A Greek Multicentre Study Assessing the Outcome of Late Rupture After Endovascular Abdominal Aortic Aneurysm Repair

Late rupture after endovascular aortic aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) is an increasing complication associated with a high mortality rate. This study aimed to analyse the causes and outcomes in patients with AAA rupture after EVAR. A multi-institutional Greek study of late ruptures after EVAR between 2008 - 2022 was performed. Primary outcomes were intra-operative and in hospital death. A total of 70 patients presented with late rupture after EVAR (proportion of ruptured EVARs among all EVARs, 0.6%; 69 males; mean age 77.2 ± 6.7 years). The mean time interval between EVAR and late rupture was 72.3 months (range 6 - 180 months). In all cases the cause of rupture was the presence of an endoleak (type I, 73%) with sac enlargement. Moreover, 34% of subjects with rupture after EVAR had been lost to follow up and 32% underwent a secondary intervention. Additionally, 57 patients (81%) were treated by conversion to open surgical repair (COSR) and the remainder by endovascular correction of endoleak (ECE). Eleven intra-operative deaths (16%) were recorded. The overall in hospital mortality rate was 41% (23% ECE vs. 46% COSR; p= .21). Of the patients who presented as initially haemodynamically stable, 23% died during hospitalisation, while the respective mortality rate for patients who presented as unstable was 78% (odds ratio [OR] 11.8, 95% confidence interval [CI] 3.6 - 39.1; p < .001). Multivariable logistic regression analysis revealed that severity of haemodynamic shock was the most significant risk factor for intra-operative (OR 7.15, 95% CI 1.58 - 32.40; p= .010) and in hospital death (OR 9.53, 95% CI 2.79 - 32.58; p < .001). These data underline the devastating prognosis of late rupture after EVAR. Haemodynamic status at presentation was an important predictive factor for death both in the ECE and COSR groups. Rigorous follow up and prompt evaluation of an unstable patient in case of rupture after EVAR is recommended.

Mortality and risk factors for ruptured abdominal aortic aneurysm after repair endovascular (rARE).

The aim of this study was to characterize risk factors for infrarenal abdominal aortic aneurysm rupture after endovascular repair (rARE) and evaluate 30-day mortality in comparison to primary ruptured abdominal aortic aneurysm (rAAA). A retrospective review of all adult patients with rAAA at a single tertiary university care center between February 11, 2006, and December 31, 2018, was performed. A total of 267 patients with rAAA were identified, 11 of whom had rARE. Descriptive statistics were applied due to the small sample size. Overall 30-day mortality was similar between primary rAAA and rARE (31.5% vs 27.3%); however, patients with rARE were more likely to receive palliative care (3.9% vs 18.2%). Mortality of patients who underwent operative intervention was 11.1% for rARE and 28.7% for primary rAAA at 30days. All patients had an endoleak at the time of rupture. Type 1 and type 3 endoleaks resulting in direct aortic sac pressurization were the primary cause of rARE (9 of 11 patients); however, rupture occurred in two patients with only a type 2 endoleak. There was no sac expansion at the time of rupture in four of 11 patients with rARE. Four of 11 patients were lost to follow-up prior to rARE. rARE is an uncommon complication following EVAR and contributes to late aneurysm-related mortality following endovascular repair. Although the 30-day mortality rate was similar for rARE and primary rAAA, larger series are required to determine which patients with rARE will benefit from intervention. The presence of endoleak and sac expansion may alert surgeons to increased risk of rARE; however, a subset of patients with rARE did not have sac expansion or surveillance imaging on follow-up. Loss to lifelong imaging surveillance remains a risk factor for rARE.

The Use of the Off-the-Shelf Inner Branch E-nside Endograft for the Treatment of Elective and Emergent Complex Aortic Aneurysms—A Single-Center Experience

The aim of this single-center study was to evaluate the early results of the off-the-shelf inner branch E-nside endograft in the treatment of complex aortic aneurysms and thoracoabdominal aortic aneurysms. We performed a retrospective analysis of a prospectively maintained database of all patients treated with the E-nside endograft at our institution during the years 2021-2023. Parameters evaluated were technical success, early major adverse events, target vessel patency, and the presence of endoleaks. In total 16 patients underwent treatment with the E-nside endograft. Six additional patients were evaluated for the device but were excluded due to anatomical considerations. Mean age was 71 (range 59-84) and 14 (88%) were males. Mean aneurysm diameter was 66mm(range 54-85). Aneurysms treated included thoracoabdominal in 9 (56%), juxtarenal aneurysms in 5 (31%), postdissection aneurysm in 1 (6%) and a type 1A endoleak after a failed endovascular aneurysm repair in 1 (6%). Five of the treated aneurysms were symptomatic. A total of 58 side branches were placed into target visceral arteries. Mean operative time was 190min (range 150-360). Technical success was achieved in 15/16 of the patients (94%). At 30days, 1 perioperative mortality and 3 major adverse events occurred, 2 of them branch related. The E-nside endograft is a feasible option for the treatment of a broad spectrumof aortic pathologies. As it is an off-the-shelf device, it can be used selectively inelective and emergent settings with acceptable30-day mortality and morbidity. Further follow-up is required to determine the durability of this treatment option and patency of side branches.

Persistent Thrombocytopenia Indicates Endoleak After Complex Endovascular Aneurysm Repair

High-pressure endoleaks (types I or III) after fenestrated-branched endovascular aneurysm repair (F-BEVAR) pose an ongoing risk of rupture. Early identification of such endoleaks may facilitate appropriate reintervention and mitigate that risk. The purpose of this study was to determine if persistent thrombocytopenia after F-BEVAR correlates with the presence of a high-pressure endoleak in the early postoperative period. Sequential patients enrolled in a physician-sponsored investigational device exemption study of physician modified and Cook manufactured F-BEVAR endografts were evaluated. Patients with type I endoleak or type III endoleak identified on computed tomography imaging within the first 6 months of follow-up were categorized as high-pressure endoleaks; any type II endoleaks were classified as low-pressure endoleaks. Univariable and multivariable analysis was performed to assess if thrombocytopenia was associated with the presence of endoleaks. We treated 185 patients. Twenty-six patients (14%) developed a high-pressure endoleak and 30 (16%) developed a low-pressure endoleak (Table I). Age, gender, race, indications for the procedure, and preoperative medications did not significantly differ between the endoleak groups. To maximize sensitivity and clinical utility, we selected a cut point of daily average platelet count of <100,000/μL (Table II). The proportion of high-pressure endoleak patients with platelet counts of <100,000/μL was significantly greater compared to patients with low-pressure and no endoleaks on postoperative day (POD) 1 through 4 (POD 4: high-pressure 42%, low-pressure 27%, no endoleak 10%; P ≤ .001). After adjusting for demographics and comorbidities, patients with high-pressure endoleak were over 12-times more likely to have a platelet count of <100,000/μL on POD 4 compared to patients with no endoleak (odds ratio, 12.3; 95% confidence interval, 3.5-43.0). F-BEVAR patients who developed high- or low-pressure endoleak were significantly more thrombocytopenic in the postoperative period. Consideration should be made to perform computed tomography imaging in patients with platelet counts of <100,000/μL persisting at POD 4 after F-BEVAR as these patients have a 35% chance of having a high-pressure endoleak requiring reintervention.Table IProportion of patients with platelet count under 100,000/μL at preoperative (day 0), and postoperative days (POD) 1-7 after F-BEVAR among the type I, II, and III endoleak and no endoleak groupsDay 0Day 1Day 2Day 3Day 4Day 5Day 6Day 7No endoleak (n = 125)12 (10)17 (14)27 (22)28 (22)13 (10)11 (9)4 (3)4 (3)T1E/T3E (n = 26)7 (27)12 (46)15 (58)12 (46)11 (42)3 (12)1 (4)1 (4)T2E (n = 30)5 (17)10 (33)11 (37)13 (43)8 (27)5 (17)3 (10)1 (3)P value.06<.001.001.02<.001.8.6a1.0aT1EL/T3EL, Type I endoleak/type III endoleak; T2EL, type II endoleak.Data presented as number (%).aFisher's exact was used. Open table in a new tab Table IIComparison of the test characteristics of a cutpoint of <100,000/μL at different postoperative days (POD) for predicting the presence of a high-pressure endoleakSensitivity (95% CI)Specificity (95% CI)PPV (95% CI)NPV (95% CI)ROC area (95% CI)Average platelets <100,000/μL on POD 30.46 (0.29-0.66)0.77 (0.70-0.84)0.30 (0.18-0.46)0.87 (0.80-0.92)0.61 (0.51-0.72.)Average platelets <100,000/μL on POD 40.42 (0.26-0.63)0.89 (0.83-0.94)0.45 (0.29-0.67)0.88 (0.82-0.93)0.66 (0.55-0.76)Average platelets <100,000/μL on POD 3 or 40.50 (0.33-0.70)0.76 (0.68-0.83)0.31 (0.19-0.47)0.87 (0.80-0.93)0.62 (0.52-0.73)95% CI, 95% Confidence interval; NPV, negative predictive value; PPV, positive predictive value; ROC, receiver operating characteristic. Open table in a new tab

Feasibility of aortic aneurysm sac embolization using a novel shape memory polymer embolic device

BackgroundWe investigated the feasibility of aneurysm sac embolization using a novel self-expanding porous shape memory polymer (SMP) device during endovascular aortic abdominal or thoracic aneurysm repair (EVAR).MethodsRetrospective analysis of consecutive patients treated at 2 centers in Germany. Patients were treated from January 2019 to July 2021 with follow-up at 7 days and 3, 6, and 12 months. Aneurysm sacs were implanted with SMP devices immediately following endograft placement during the same procedure. Primary endpoint was technically successful SMP-device deployment into the aneurysm sac outside the endograft. Secondary endpoints were changes in aneurysm volume and associated complications (e.g., endoleaks).ResultsWe included 18 patients (16 males), aged 72 ± 9 years, achieving 100% technical success. Mean preprocedure aortic aneurysm sac volume was 195 ± 117 mL with a perfused aneurysm volume of 97 ± 60 mL. A mean of 24 ± 12 SMP devices per patient were used (range 5–45, corresponding to 6.25–56.25 mL expanded embolic material volume). All evaluable patients exhibited sac regression except 2 patients yet to reach 3-month follow-up. At mean 11 ± 7 months (range 3–24), change in aneurysm volume from baseline was -30 ± 21 mL (p < 0.001). In 8 patients, aneurysm regression was observed despite type 2 endoleaks in 6 and type 1A endoleaks in 2, none of them requiring further intervention to date. No morbidity or mortality related to this treatment occurred.ConclusionsSMP devices for aortic aneurysm sac embolization during endovascular repair appear feasible and safe in this small case series. Prospective studies are needed.Key points• Shape memory polymer is a novel, self-expanding, porous, and radiolucent embolic device material.• Aortic aneurysm sacs were treated with polymer devices immediately following endograft placement.• Aortic aneurysm sac regression was observed in all patients with over 3-month follow-up.• Aortic aneurysm sac regression was observed even in the presence of endoleaks.

Volumetric analysis of effectiveness of embolization for preventing type II endoleaks following endovascular aortic aneurysm repair

Objective: The presence of endoleak was associated with the failure of endovascular aortic aneurysm repair (EVAR) treatment. The key to eliminating type II endoleak has shifted from reintervention to prevention. This study aimed to evaluate the effectiveness and safety of applying fibrin sealant to prevent type II endoleak in conjunction with EVAR.

The impact of completion and follow-up endoleaks on survival, reintervention, and rupture

ObjectiveEndoleaks may be seen at case completion of endovascular abdominal aortic aneurysm repair (EVAR), and the presence of an endoleak may impact outcomes. However, the clinical implications of various endoleaks seen during follow-up is not well-described. Therefore, we studied the impact of endoleaks at completion and at follow-up on mid-term outcomes. MethodsWe reviewed patients who underwent EVAR from 2003 to 2016 within the Vascular Quality Initiative-Medicare database and identified patients with endoleak at procedure completion and during follow-up, excluding those presenting with rupture. We stratified cohorts by presence of completion and follow-up endoleak subtypes. The primary outcome was 5-year survival, and secondary outcomes included 5-year freedom from reintervention and freedom from rupture. We used Kaplan-Meier estimates and log-rank tests to analyze differences in time-to-event endpoints. ResultsOf 21,745 patients with completion endoleak data, 5085 (23%) had an endoleak. Compared with those without endoleak, those with type I endoleaks had lower 5-year survival (69% vs 75%; P < .001), type II endoleaks had higher survival (79%; P < .001), and types III, IV, and indeterminate were not statistically different (73%, 73%, and 75%, respectively). Freedom from reintervention for types I and III endoleaks were significantly lower than no endoleak cohort (I: 76%; P < .001; III: 72%; P < .001 vs 83%), but freedom from rupture was higher for those with type II and III endoleak (95% and 97% vs 94%; P < .001). Of 14,479 patients with detailed follow-up endoleak data, 2290 (16%) had an endoleak. Compared with those without endoleak, types I and III had significantly lower 5-year survival (I: 80%; P = .002; III: 66%; P < .001 vs 84%), but there were no differences for types II (82%) and indeterminate (77%). Those with any type of follow-up endoleak had lower 5-year freedom from reintervention (I: 70%; P < .001; II: 76%; P = .006; III: 36%; P < .001; indeterminate: 60%; P = .007 vs 84%), and lower freedom from rupture (I: 92%; P < .001; II: 91%; P = .16; III: 88%; P = .01; indeterminate: 90%; P = .11 vs 94%). ConclusionsCompared with patients with no endoleak, those with type I completion endoleaks have lower 5-year survival and freedom from reintervention. Patients with types I and III follow-up endoleaks also have lower survival, and any endoleak at follow-up is associated with lower freedom from reintervention and freedom from rupture. These data highlight the importance of careful patient selection and close postoperative follow-up after EVAR, as the presence of endoleaks, specifically type I and III, over time portends worse outcomes.

Internal Iliac Artery Embolization within EVAR Procedure: Safety, Feasibility, and Outcome.

This study is focused on Internal Iliac Artery (IIA) embolization in patients undergoing Endovascular Aneurysm Repair (EVAR). Our aims were: to establish the feasibility of the procedure; to assess the presence of endoleak (EL) and increase in the size of the sac at follow-up; to define the need for reintervention; and to evaluate mortality rate. In this retrospective single-center study, EVAR-treated patients with an embolization of IIA were chosen. Coils and vascular plug were used as embolizing agents. A total of 49 participants were enrolled in the study (48 men and one woman) with a median age of 76 ± 12 years. Patients had no early EL in 87.75% of cases, 8.16% had type 1a EL, 2.04% type 1b EL, and 2.04% type 2 EL, with a comprehensive technical success of 95.91%. In the follow-up, at 1 month 72.22% remained without EL, at 6 months 70.97%, and at 1 year 81.48%. In the same period, the trend of type 1 EL was 5.56% (1 month), 3.23% (6 months), and 0% (1 year). For EL type 2: 22.22% at 1 month, 25.81% at 6 months, and 16.7% at 1 year. The overall mortality was 35.58% and the re-intervention rate was 16.33%. IIA embolization is a feasible and safe procedure. The presence of EL is not superior to EVAR procedures that do not involve embolization.

Clinical Evaluation of Non-Contrast-Enhanced Radial Quiescent-Interval Slice-Selective (QISS) Magnetic Resonance Angiography in Comparison to Contrast-Enhanced Computed Tomography Angiography for the Evaluation of Endoleaks after Abdominal Endovascular Aneurysm Repair

Contrast-enhanced (CE) angiographic techniques, such as computed tomographic angiography (CE-CTA), are most commonly used for follow-up imaging after endovascular aneurysm repair. In this study, CE-CTA and non-CE QISS-MRA were compared for the first time for assessing endoleaks and aneurysms at follow-up after abdominal EVAR. Our study included 20 patients (17 male, median age 79.8 years) who underwent radial QISS-MRA and CE-CTA after EVAR at their first follow-up examination. Two interventional radiologists evaluated datasets from both techniques in each patient concerning presence of endoleaks, types of endoleaks, aneurysm diameter, and image quality. Interobserver and intermodal agreement were assessed with Cohen's Kappa. Image quality was rated as excellent or good for both modalities by both observers. Ferromagnetic embolization materials cause hyperdense artifacts in CE-CTA causing aneurysm sac diameter measurements to be inaccurate by up to 1 cm. Type 2 endoleaks with low-flow characteristics in CE-CTA were overlooked compared to radial QISS-MRA. Compared to CE-CTA, all endoleaks after abdominal EVAR were detected and classified correctly on QISS-MRA. The interobserver agreement between CE-CTA and QISS-MRA was almost perfect, except for type 2 endoleaks, where agreement was substantial. Intermodal aneurysm diameter correlate "very strongly" for both observers. Radial QISS-MRA is a contrast agent free technique for diagnosing and monitoring all types of endoleaks and aneurysms in patients after abdominal EVAR. It provides information about specific clinical questions concerning aneurysm diameter and presence and types of endoleaks without radiation exposure and the side effects associated with iodine-based contrast agents.

Endovascular treatment of type „A“ and type „B“ dissection of the aorta

During the period from March 2014 to May 2018, endovascular treatment of aortic dissection type A and type B was carried out in a total of 70 patients. Patients were divided into two groups, aortic dissection type A (14 patients) and type B (56 patients), a group-by-group descriptive analysis was conducted, and then a comparison was done between the two patient groups. &amp;nbsp;The aim of the study was to establish the effective use of endovascular treatment in type A and type B aorta dissection. As a result of the survey, data on the demographic characteristics and risk profile of these patients are accumulated for the first time in Bulgaria. Endovascular treatment options for the treatment of aortic dissection type A and type B, as well as malperfusion syndrome, are examined, demonstrating their effectiveness and safety. As a result of the study, it is proven that endovascular treatment in aortic dissection type A and type B leads to a significant increase in the size of the true lumen and reduction of the false lumen, which leads to an improvement in perfusion and reduces the risk of developing an aneurysm and rupture. &amp;nbsp;The presence of endoleak and persistent communication between the false and the real lumen are the most common causes of re-intervention, such as endovascular options are most often the first line for their dealing and are proven to be effective and safe. &amp;nbsp;Treatment of dissection of the aorta type A and B is not a one-time act, but requires periodic diagnostic control and, if necessary, surfery and/or endovascular corrections of the complications that have arisen.

Outcomes of Gore iliac branch endoprosthesis with internal iliac component versus Gore Viabahn VBX

ObjectiveThe Gore Excluder iliac branch endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, AZ) is the only iliac branch device approved in the United States to preserve blood flow to the external and internal iliac arteries (IIAs). Some surgeons have used the Gore Viabahn VBX balloon expandable endoprosthesis (VBX; W.L. Gore & Associates) in the IIA rather than the self-expanding endograft designed for the IBE, the internal iliac component (IIC). The objective of the present study was to examine the outcomes for patients treated for aortoiliac artery aneurysms using the IBE with either the IIC or VBX stent. MethodsWe performed a retrospective, single-center review of patients treated for aortoiliac artery aneurysms using the Gore IBE device, with either the IIC or VBX stent into the IIA, from February 2016 to March 2021. The patient demographics, procedure details, 30-day morbidity and mortality, and 6-month and 1-year outcomes and mortality were analyzed. The categorical factors are summarized using frequencies and proportions. Continuous measures are summarized as the mean ± standard deviation. A significance level of P = .05 was assumed for all test results. The analyses were performed using SAS software, version 9.4 (SAS Institute, Cary, NC). ResultsA total of 62 patients (64 arteries) had undergone elective aortoiliac artery aneurysm repair with the IBE. The IIC was used exclusively in 35 cases (55%) and the VBX in 29 (45%). The patients who had received the VBX had had a higher American Society of Anesthesiologists class (P = .006). Upper extremity access was used for VBX delivery in 24.1% of the procedures. No return to the operating room was required in either group. No differences were found in technical success (IIC, 97.1%; VBX, 93.1%; P = .59), the presence of endoleak on completion (20.0% vs 6.9%; P = .17), readmission (97.1% vs 93.1%; P = .59), or mortality (1.6% vs 0%; P = .45) at 30 days. No differences were found in the requirement for any IBE reintervention after 30 days. No type Ia, Ib, or III endoleaks had occurred in either group at any follow-up point. No significant difference was found in internal iliac limb primary patency (IIC, 100%; VBX, 96.3%) between groups. A nonstatistically significant trend was found toward fewer trunk–ipsilateral leg type II endoleaks in the VBX group during follow-up. ConclusionsThese data suggest that the VBX is a reasonable substitute for the IIC, with a comparable safety and efficacy profile. Given its inherent conformability, greater range of diameters, and longer working length, the VBX stent offers expanded IIA branch options with the IBE.

Endovascular Repair Of Delayed Endologix AFX Graft Failure Is Superior To Open Repair With Explant

<h3>INTRODUCTION AND OBJECTIVES</h3> Prior studies have described delayed failure of the Endologix Endovascular AAA System (AFX) with resultant aneurysm sac pressurization and increased risk of rupture. While there is no consensus on operative strategy to deal with this endograft failure, options include re-lining with a contemporary endograft or open graft explant. The purpose of this study is to compare these two surgical treatment options in our own single institution experience. <h3>METHODS</h3> A retrospective review was performed of 122 AFX endografts implanted at our tertiary care center from 2013-2019. Thirty-seven patients were found to have delayed endograft failure and subsequently underwent re-line(n=25) or explant(n=12). All re-interventions were performed for endoleak identified on imaging, sac expansion, and/or rupture. Primary composite outcome was successful aneurysm exclusion without mortality at 30-days. Secondary endpoints included hospital length of stay and operative time. Patients without appropriate follow-up were excluded unless death occurred within the perioperative period. <h3>RESULTS</h3> Thirty-seven patients were identified, of which 25 underwent re-line and 12 explant. There were no differences in age, gender, race comparatively(p>0.05), or reason for re-intervention (presence of endoleak, endoleak type, rupture)(p>0.05) There was no significant difference in the primary composite endpoint of successful aneurysm exclusion without death within 30-days between graft re-line(76.0%) and explant(75.0%) (p=0.95). Graft re-line had a significantly shorter hospital length of stay (2.20±2.25d vs. 8.64±7.38d (p<0.01)) and operative time (164.1±110.4min vs. 272.6±113.7min (p=0.01)). Additionally, operative time for the re-line cohort was not significantly different than that of their original EVAR(p=0.29). There were 3(25%) deaths in the explant cohort compared to zero in the re-line cohort although 2(8%) went on to require explant. <h3>CONCLUSIONS</h3> Endograft re-line, although off IFU, does produce analogous aneurysm exclusion rates when compared to explant in Endologix AFX failures, with a reduction in OR time, hospital length of stay and mortality.

Mid-term outcomes of hybrid debranching endovascular aortic arch repair in landing zones 0-2.

The aim of this study is to summarize a single-center experience of hybrid debranching endovascular repair of the aortic arch and proximal descending thoracic aorta (DTA) with regard to the mid-term outcomes with highlighting the difference between the landing zones 0-2. A retrospective review of data from a prospectively collected registry (Gangnam Severance Endovascular Aortic Registry) was performed. From among 332 patients whose aortic pathology was managed with TEVAR, 112 patients who underwent hybrid arch repair during the study period between 2012 and 2016 were identified. The patients were grouped into three cohorts according to the proximal landing zones (0, 1, and 2) of Ishimaru. The early outcome (30-days) in terms of mortality, morbidity, supra-aortic vessels patency, and presence of endoleak were analyzed. The survival, freedom from re-intervention, and major complications during follow-up were demonstrated. During the study period. 112 patients (mean age 65±7, 79% males) were included. The patients were distributed in three cohorts: 8 (7%) patients with proximal landing zone 0, 20 (18%) with zone 1, and 80 (75%) with zone 2 hybrid aortic arch repair. Technical success was achieved in 7 (88%), 19 (90%), and 79 (94%) patients for zones 0, 1, and 2, respectively. The mean intensive care unit (ICU) stay was shorter in zone 2 (p = .005). The mean total hospital stay was shorter in zone 2 (p = .03). The overall in-hospital mortality rate was 5% (4/112). There was no spinal cord ischemia or early surgical conversion. Renal function deterioration was seen more but not significantly in zone 0 patients (p = .08). Respiratory failure was seen significantly in zone 0 patients (p = .01). Stroke occurred in 6/44 (14%) patients with degenerative aneurysm versus 1/60 (2%) patients with aortic dissection (p =.06). Early CTA showed 100% patency of the supra-aortic vessels. The early endoleak rate was significant in zone 0 patients (p = .008). The mean follow-up period was (32±19months). The survival rates and freedom from re-intervention were not statistically significant among the three zones. However, the survival rate and freedom from intervention tend to be higher in zone 2 versus zone 0 (p = .07 and .09), respectively. Hybrid debranching endovascular aortic arch repair is feasible and relatively safe with acceptable mid-term outcomes. Zone 0 patients has worse early and late outcomes in comparison to other zones. Careful patient selection and improved endovascular technology may be the key to improve the outcomes.

Safety and Validity of the Proposed European Society for Vascular Surgery Infrarenal Endovascular Aneurysm Repair Surveillance Protocol: A Single Centre Evaluation

Long term surveillance after endovascular aneurysm repair (EVAR) is essential to detect late complications, but there is variation in practice. The European Society for Vascular Surgery (ESVS) made a recommendation for a new surveillance protocol; one element involves risk stratifying patients depending on sac size reduction and presence of endoleak at their 30 day computed tomography angiogram into low risk groups (delayed imaging to five years) or higher risk groups (continue with the current protocol). The aim was to test this suggested protocol retrospectively within an EVAR patient cohort. Data on EVARs performed from October 2009 to October 2019 were collected. Information gathered from an existing surveillance programme was used to assess the proposed ESVS protocol. All patients who underwent re-intervention were reviewed to see whether adopting the proposed ESVS protocol would have detected these events. In total, 309 procedures were included. Altogether, 219 of these patients had no endoleak (70.9%) and 86 had a type II (27.8%) endoleak. Only four developed a type I or III endoleak. No patient in the low risk cohort (no initial endoleak or sac shrinkage > 1 cm) required secondary intervention. Five year follow up data were available for 103 patients. In the type II endoleak group, there were 28 secondary interventions in 22 patients. No patient experienced a ruptured aneurysm within five years post-operatively. Had the proposed ESVS protocol been followed, all patients requiring a secondary intervention or with increasing sac size would have been detected/captured. Further, adherence to the ESVS guidelines would have resulted in 103 patients with a five year follow up history qualifying for reduced surveillance. A further 120 patients who had reached the three and four year follow up timepoints could have qualified for a reduced surveillance, reducing imaging cost further. Adopting the proposed ESVS EVAR surveillance protocol safely identified “low risk” patients who did not go on to require a secondary intervention. These patients could benefit from reduced surveillance scanning.

Safety and Validity of the Proposed European Society for Vascular Surgery Infrarenal Endovascular Aneurysm Repair Surveillance Protocol: A Single Centre Evaluation

Long term surveillance after endovascular aneurysm repair (EVAR) is essential to detect late complications, but there is variation in practice. The European Society for Vascular Surgery (ESVS) made a recommendation for a new surveillance protocol; one element involves risk stratifying patients depending on sac size reduction and presence of endoleak at their 30 day computed tomography angiogram into low risk groups (delayed imaging to five years) or higher risk groups (continue with the current protocol). The aim was to test this suggested protocol retrospectively within an EVAR patient cohort. Data on EVARs performed from October 2009 to October 2019 were collected. Information gathered from an existing surveillance programme was used to assess the proposed ESVS protocol. All patients who underwent re-intervention were reviewed to see whether adopting the proposed ESVS protocol would have detected these events. In total, 309 procedures were included. Altogether, 219 of these patients had no endoleak (70.9%) and 86 had a type II (27.8%) endoleak. Only four developed a type I or III endoleak. No patient in the low risk cohort (no initial endoleak or sac shrinkage > 1 cm) required secondary intervention. Five year follow up data were available for 103 patients. In the type II endoleak group, there were 28 secondary interventions in 22 patients. No patient experienced a ruptured aneurysm within five years post-operatively. Had the proposed ESVS protocol been followed, all patients requiring a secondary intervention or with increasing sac size would have been detected/captured. Further, adherence to the ESVS guidelines would have resulted in 103 patients with a five year follow up history qualifying for reduced surveillance. A further 120 patients who had reached the three and four year follow up timepoints could have qualified for a reduced surveillance, reducing imaging cost further. Adopting the proposed ESVS EVAR surveillance protocol safely identified "low risk" patients who did not go on to require a secondary intervention. These patients could benefit from reduced surveillance scanning.

The Prophylaxis of Type 2 Endoleaks is Relevant for Long Term Success of EVAR

One out of 8 patients needs a reintervention after EVAR during the first 5 years. Two thirds of secondary interventions aim at treating endoleaks. The prevalence of complications doubles in the presence of endoleaks. Fourth generation stent grafts do not lead to a decrease in Type 2-associated reinterventions, but to better prevention of Type 1 and 3 endoleaks. Pretreatment of potential type 2 feeding arteries with embolising agents and treatment of the occurrence of type 2 endoleaks.