Primary Endovascular Aneurysm Repair Research Articles

Editor's Choice – The Impact of Centralisation and Endovascular Aneurysm Repair on Treatment of Ruptured Abdominal Aortic Aneurysms Based on International Registries

Current management of ruptured abdominal aortic aneurysms (RAAA) varies among centres and countries, particularly in the degree of implementation of endovascular aneurysm repair (EVAR) and levels of vascular surgery centralisation. This study assesses these variations and the impact they have on outcomes. RAAA repairs from vascular surgical registries in 11 countries, 2010-2013, were investigated. Data were analysed overall, per country, per treatment modality (EVAR or open aortic repair [OAR]), centre volume (quintiles IV), and whether centres were predominantly EVAR (≥50% of RAAA performed with EVAR [EVAR(p)]) or predominantly OAR [OAR(p)]. Primary outcome was peri-operative mortality. Data are presented as either mean values or percentages with 95% CI within parentheses, and compared with chi-square tests, as well as with adjusted OR. There were 9273 patients included. Mean age was 74.7 (74.5-74.9) years, and 82.7% of patients were men (81.9-83.6). Mean AAA diameter at rupture was 7.6cm (7.5-7.6). Of these aneurysms, 10.7% (10.0-11.4) were less than 5.5cm. EVAR was performed in 23.1% (22.3-24.0). There were 6817 procedures performed in OAR(p) centres and 1217 performed in EVAR(p) centres. Overall peri-operative mortality was 28.8% (27.9-29.8). Peri-operative mortality for OAR was 32.1% (31.0-33.2) and for EVAR 17.9% (16.3-19.6), p<.001, and theadjusted OR was 0.38 (0.31-0.47), p<.001. The peri-operative mortality was 23.0% in EVAR(p) centres (20.6-25.4), 29.7% in OAR(p) centres (28.6-30.8), p<.001; adjusted OR=0.60 (0.46-0.78), p<.001. Peri-operative mortality was lower in the highest volume centres (QI>22 repairs per year), 23.3% (21.2-25.4) than in QII-V, 30.0% (28.9-31.1), p<.001. Peri-operative mortality after OAR was lower in high volume centres compared with the other centres, 25.3% (23.0-27.6) and 34.0% (32.7-35.4), respectively, p<.001. There was no significant difference in peri-operative mortality after EVAR between centres based on volume. Peri-operative mortality is lower in centres with a primary EVAR approach or with high case volume. Most repairs, however, are still performed in low volume centres and in centres with a primary OAR strategy. Reorganisation of acute vascular surgical services may improve outcomes of RAAA repair.

Incidence and treatment results of Endurant endograft occlusion

The Endurant endograft (Medtronic Inc, Minneapolis, Minn) is a new-generation device specifically developed to perform well in complex abdominal aortic aneurysm anatomy. Previous reports on the 1- and 2-year results of endovascular aneurysm repair (EVAR) with the Endurant endograft showed excellent outcome, including prevention of migration and type I endoleaks, but occurrence and outcome of post-EVAR occlusion have not been determined in a large multicenter patient cohort with midterm follow-up, which is the objective of this study. Data of consecutive patients treated with the Endurant from December 2007 to April 2012 in three Dutch tertiary vascular referral hospitals were prospectively gathered and retrospectively analyzed. Follow-up consisted of regular office visits, computed tomography angiography at 1 and 12 months after EVAR, and subsequently, duplex ultrasound imaging or computed tomography angiography at regular intervals. Patients with ruptured aneurysms or with earlier abdominal aortic surgery were excluded. The incidence and clinical outcome of endograft occlusions were analyzed. An expert review board assessed all cases in the search for possible causes of occlusion. Included were 496 patients (87.7% male), who were a median age of 74 years (range, 68-78 years). Median follow-up was 1.7 years (range, 0-4.6 years). Twenty graft occlusions (4.0%) occurred during follow-up. Median time between primary EVAR and detection of the occlusion was 1 month, with 55% occurring ≤ 60 postoperative days and 90% ≤ 1 year. No association was found between occlusion and sex (P = .28), age (P = .96), or use of an aortouniiliac device (P = .66). Technical error was the considered cause of the occlusion in 12 patients (60%). The estimated freedom from occlusion was 98.4% at 30 days, 95.7% at 1 year, and 95.3% at 3 years. Presenting symptoms of occlusion were acute limb ischemia in 50%. Treatment was surgical (75%) or percutaneous (25%). Successful revascularization was achieved in 17 of 20 patients, but reocclusions occurred in five, resulting in a transfemoral amputation in one patient. Occlusion-related mortality was 0.6% (3 of 496). At a median follow-up of 1.7 years, Endurant endograft occlusion occurred in 4.0% of 496 patients. Most occlusions occurred ≤ 2 months after EVAR, and rarely after 1 year. A technical justification for occlusion could be found for 60% of patients. A more liberal intraoperative and early postoperative (re)intervention strategy may reduce the occlusion rates and improve outcome.

Long-term Follow-up of Secondary Interventions After Endovascular Aneurysm Repair With the AneuRx Endoprosthesis: A Single-Center Experience

To evaluate initial and long-term results of secondary interventions after endovascular aneurysm repair (EVAR) with an AneuRx endoprosthesis. Between 1996 and 2003, an AneuRx device was used primarily in 212 patients (197 men; mean age 71+/-7.0 years). Sixty-two (29%) patients (58 men; mean age 73+/-7.2 years) required a secondary intervention (percutaneous, endovascular, or open repair) after EVAR and were prospectively followed after their secondary interventions. Data were analyzed retrospectively. Of the 212 AneuRx patients, 59 (28%) required secondary interventions for endoleaks (28 type Ia, 6 type Ib, 8 type II, and 17 type III) and 3 (1%) for obstruction of the endoprosthesis. The mean interval between primary EVAR and secondary intervention was 39+/-30 months. The yearly risk of requiring a secondary intervention after receiving a primary AneuRx graft was 3.7%. Overall 30-day morbidity after a secondary intervention was 18% (11/62); the 30-day mortality was 5% (3/62). Short endovascular extender cuffs were used for type Ia endoleaks in 23 of 28 patients. Over a mean follow-up of 81+/-34 months after the secondary intervention, the success of short endovascular cuffs for treatment of type Ia endoleak was 52% (12/23); the remaining 11 (48%) patients required additional reinterventions for recurrent endoleak or persistent aneurysm growth. Patients with a primary AneuRx stent-graft had an acceptable yearly risk of requiring a secondary intervention following EVAR, but 30-day morbidity and mortality rates were significant and must be taken into account during primary decision making for endovascular or open repair. Proximal extender cuffs may not be a durable treatment for type Ia endoleak.

Deteriorating Consumptive Coagulopathy with Type III Endoleak Following Endovascular Repair for Abdominal Aortic Aneurysm Associated with Liver Cirrhosis

To report a case of deteriorating consumptive coagulopathy with type III endoleak following endovascular aneurysm repair (EVAR) of the abdominal aorta associated with liver cirrhosis. A 72-year-old man with liver cirrhosis developed type III endoleak following EVAR. Spontaneous intramuscular hematoma developed due to deteriorating consumptive coagulopathy induced by type III endoleak and liver dysfunction. Although additional EVAR was performed at 52 months after primary EVAR, the patient died due to multiorgan failure and multifocal hematoma of the muscles and subserosa. EVAR for patients with liver dysfunction and coagulopathy should be considered with great caution. We suggest that prompt and adequate treatment using an endovascular technique or surgical repair should be performed for patients with liver dysfunction, coagulopathy, and turbulent endoleak, even if the coagulopathies are worse compared to before EVAR.