Abdominal Aneurysm Repair Research Articles

Low-Profile Minos TM Stent Graft System for Endovascular Abdominal Aorta Aneurysm Repair—Early and Late Outcomes in Elective and Emergent Situations

BackgroundThe aim of the study was to present the results of a novel abdominal stent graft for patients with Abdominal aortic aneurysm (AAA), through 2 years follow-up. MethodsA single-center retrospective review with prospectively collected data was performed to assess the safety and effectiveness of the Minos Abdominal stent device for treating abdominal aortic aneurysms. We estimated technical success rate, in-hospital and 30-day mortality, and mortality at the end of follow-up as well as complication and reintervention rate in our study cohort. Follow-up imaging assessments consisted of computed tomography angiography (CTA) at 1 and 6 months and yearly thereafter. ResultsA total of 52 patients (92% males; mean age, 74±6 years) were enrolled with Minos Abdominal stent device from July 2020 until September 2023. Thirty one (60%) patients were asymptomatic while 21 (40%) were symptomatic. The technical success of the endovascular aortic repair (EVAR) was 95% (49/52 patients). In 5% (3/52) of the cases, cannulation of the contralateral limb was unsuccessful and was converted to aorto-uni-iliac graft (AIU). Two (4%) aortic related death were recorded during the 30-day period. The major adverse event rate was 3.8%. The overall mean follow-up was 30±6 months; no aorta-related deaths or graft related complications were observed. Sac shrinkage (>5mm) has been observed in 70% of patients. ConclusionsMinos endoprosthesis seems to be safe, effective and durable for treating AAA either in elective or emergent situations.

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.

Totally percutaneous abdominal and thoracic endovascular aneurysmal repair: 10-year experience of a tertiary cardiologic center

Totally percutaneous abdominal and thoracic endovascular aneurysmal repair: 10-year experience of a tertiary cardiologic center

Open Surgery for Pseudoaneurysm after EVAR: A Unique Surgical Challenge

Endovascular repair of abdominal aneurysm (EVAR) has become the main stay of treatment for abdominal aortic aneurysm. Long-term follow-up studies have shown a variety of complications following EVAR, few of which are dangerous with high morbidity and mortality. Open surgery for complications of EVAR poses unique challenges to the surgeon. We present one of the serious complications following EVAR which was successfully managed by open surgery.

Predictive Factors for Iliac Limb Occlusions After Endovascular Abdominal Aneurysm Repair: Determined from Aortoiliac Anatomy, Endovascular Procedures, and Aneurysmal Remodeling.

Iliac limb occlusion (ILO) is a serious complication of endovascular abdominal aneurysm repair (EVAR). This study aimed to identify predictive factors for ILO derived from aortoiliac morphology, endovascular procedure-related parameters, and aneurysmal remodeling characteristics. Patient demographics, pre-EVAR anatomical characteristics of the aneurysm, endovascular procedure details, and post-EVAR aneurysmal remodeling outcomes were analyzed and compared using univariate analysis. Statistically significant factors were subsequently subjected to Cox regression and Kaplan-Meier analyses. Between January 2013 and April 2022, 66 patients were included in this study. Fourteen patients presented with ILO and were compared with 52 control patients with patent endograft limb over at least 1-year of follow-up. The tortuosity indices of the common iliac artery (CIA) and endograft iliac limb to vessel oversizing were significantly larger in the ILO group than in the patent endograft limb group. The CIA index of tortuosity ≥1.08, and endograft iliac limb to vessel oversizing ≥18.8% were independent predictors for ILO. During the follow-up of all patients, the proximal aortic neck and CIA diameters increased, aneurysm sac diameter decreased, and aortic neck and aortic length increased. The aortoiliac length increased over time in patients with patent endograft limb but not in patients with ILO. A change in the lowest renal artery-left iliac bifurcation distance ≦0.07 mm increased the risk of ILO. ILO is predisposed to occur when the CIA index of tortuosity ≥1.08 and endograft iliac limb to vessel oversizing ≥18.8% are present. Significant aortoiliac remodeling, including proximal aortic neck dilatation, neck straightening, aneurysmal sac regression, iliac artery enlargement, and aortic lengthening, occurs after EVAR. Aortoiliac elongation was observed in patients with patent endograft limb, but not in patients with ILO. ILO was associated with a change in the lowest renal artery-left iliac bifurcation from the postoperative measurements ≦ 0.07 mm.

Effectiveness and Safety of Endoanchors in Abdominal and Thoracic Endovascular Aneurysm Repair: A Systematic Review and Meta-analysis

Purpose: This systematic review aimed to summarize the effectiveness and safety of endoanchor, a stabilizing device for the proximal endograft designed to prevent endoleak and stent migration in endovascular aneurysm repair (EVAR) and thoracic endovascular aneurysm repair (TEVAR). Materials and methods: A systematic review and meta-analysis was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. Literature up to May 31, 2023 was searched and independently screened from 4 databases. Data were pooled for meta-analysis. Primary outcomes included intraoperative and follow-up endoleak, stent migration, and reintervention rates; sac regression; and 30-day all-cause mortality. Results: Sixteen EVAR (n=1145) and 6 TEVAR studies (n=163) using the Heli-Fx EndoAnchor system were included from 2225 retrieved records. For EVAR patients (mean follow-up=11.9 months), the endoleak, graft migration, and reintervention rates were 3.97% (95% confidence interval [CI]=0.36%-1.99%), 0.004% (95% CI=0.00%-0.76%), and 5.43% (95% CI=0.86%-12.54%), respectively. The endoleak rates for primary and revision EVAR were 0.16% (95% CI=0.00%-1.65%) and 3.60% (95% CI=0.14%-9.72%), respectively. Only 4 cases of 30-day mortality (n=4) were reported in the literature. For TEVAR patients, the endoleak, stent migration, and reintervention rates were 7.4% (95% CI=0.03%-0.13%), 0.2% (95% CI=0.00%-0.06%), and 17.1% (95% CI=0.01%-0.45%), respectively. The 30-day mortality was 0.9% (95% CI=0%-0.12%). Conclusions: Endoanchor fixation in EVAR and TEVAR is effective and safe in preventing and treating endoleak and stent migration. The mortality is minimal in EVAR but higher in TEVAR. Clinical Impact Endoleak, graft migration, and reintervention in EVAR and TEVAR with endoanchor use were rare. Mortality in EVAR was low. The adjunctive deployment of endoanchors is an effective and safe means to prevent and treat endoleak and stent migration in EVAR and TEVAR. Yet, long-term efficacy and safety data and randomized controlled trials would be required to definitively recommend endoanchor use in routine clinical practice.

Can HALP score predict post-contrast acute kidney injury and 6-year mortality in patients undergoing endovascular abdominal aneurysm repair?

The aim of this study is to investigate the relationship between HALP score and post-contrast acute kidney injury (PC-AKI) and average 6-year mortality in patients undergoing endovascular abdominal aortic aneurysm repair (EVAR). 125 patients who underwent EVAR between January 2015 and December 2020 were included in our study. HALP score was calculated with the formula "hemoglobin × albumin × lymphocyte count/platelet count." In the first phase of the study, two groups were developed: those who developed PC-AKI and those who did not. In the second stage, statistical analysis was performed by creating two groups: average 6-year mortality and survivors group. HALP score was found to be lower in the PC-AKI group [26.12 (14-61.54) versus 40.53 (7.22-103.61); p < .001]. Low HALP score was found to be both a dependent and independent predictor of the development of PC-AKI (p = .019). HALP score was also found to be lower in the mortality group compared to the survivors [28.97 (12.6-103.61) versus 40.81 (7.22-99) p = .004]. Low HALP score was found to be only a dependent predictor of mortality. The development of PC-AKI was found to be an independent predictor of mortality (p = .042). The HALP score, which can be calculated with a simple formula, can be used to predict PC-AKI and medium-long-term mortality in EVAR patients.

Center-level outcomes following elective fenestrated endovascular aortic aneurysm repair in the Vascular Quality Initiative database

ObjectiveHospital volume is associated with mortality after open aortic aneurysm repair. Fenestrated and branched endovascular aortic repair (B-FEVAR) has been increasingly used for repair of complex thoracoabdominal and juxtarenal aneurysms, but evidence of a center-volume relationship is limited. We aimed to measure the association of center volume with in-hospital mortality, postoperative outcomes, and 1-year survival following B-FEVAR. MethodsPatients undergoing elective endovascular thoracoabdominal and complex abdominal aneurysm repair with branch intervention (2014-2021) listed within the national Vascular Quality Initiative Thoracic Endovascular Aortic Repair/Complex EVAR database were analyzed. Centers were grouped into quartiles by mean annual procedure volume. Multivariable regression was used to evaluate the effect of center volume on in-hospital mortality adjusting for baseline and procedural characteristics. Kaplan-Meier estimation, log rank test, and mixed effects Cox regression were used to evaluate 1-year survival. ResultsA total of 4302 adult elective F-BEVAR procedures were identified at a total of 163 centers. In-hospital mortality did not differ by hospital volume (quartile [Q]1 = 35/1059 [3.3%]; Q2 = 30/1063 [2.8%]; Q3 = 33/1120 [2.9%]; and Q4 = 44/1060 [4.2%]; P = .308). The high volume group had a higher rate of major complication (Q1 = 14.9%; Q2 = 12.8%; Q3 = 13.3%; and Q4 = 20.1%; adjusted P < .001). Physician-modified grafts were more frequently employed in high-volume centers (Q1 = 4.5%; Q2 = 18.7%; Q3 = 11.3%; and Q4 = 19.2%; P < .001), with a decreased incidence of any endoleak noted at the end of the procedure (Q1 = 34.9%; Q2 = 32.8%; Q3 = 30.0%; and Q4 = 29.0%; P = .003). In the multivariable analysis, in-hospital mortality was not associated with center volume, comparing very low volume to medium- and high-volume centers (odds ratio [95% confidence interval] vs Q4: Q1 = 1.1 [0.6-1.9], Q2 = 0.6 [0.4-1.1], and Q3 = 0.9 [0.5-1.5]; all P > .05). No significant difference was found in 1-year survival between center volume groups. ConclusionsIn-hospital mortality is not associated with procedure volume within centers performing complex endovascular aortic repair. However, complication rates and endoleak may be associated with procedure volume. Long-term outcomes by annualized procedure volume, specifically graft durability and sac expansion, should be investigated.

Intravascular Iliac Artery Lithotripsy to Facilitate Aortic Endograft Delivery: Midterm Results of a Dual-Center Experience.

To assess the feasibility and safety of intravascular lithotripsy (IVL) for enabling transfemoral abdominal (EVAR), thoracic (TEVAR), and thoracoabdominal (BEVAR) endovascular aneurysm repair in patients with narrow and calcified iliac arteries. Consecutive patients treated with IVL for severe calcified and narrowed iliac access before EVAR, TEVAR, or BEVAR between November 2020 and June 2022 were retrospectively evaluated. All anatomical iliac characteristics were acquired by multi-planar reconstruction of preoperative computed tomography angiography (CTA). The hostility of the vascular accesses was classified based on Peripheral Arterial Calcium Scoring System (PACSS) and calcified access severity score (CASS), a new score considering both anatomical (calcium grade and length, minimum lumen diameter [MLD], and tortuosity index) and aortic stent-graft (SG/MLD index) parameters. Primary endpoint was technical success defined as successful aortic endograft delivery and deployment without iliac rupture. Freedom from complications and primary patency were additionally analyzed. Twenty-eight iliac axes were treated with IVL (8 bilateral) in 20 patients (mean age 74.5±6.7 years) with a mean follow-up of 26.5±6.2 (range 17-36) months. Ten patients underwent EVAR: 3 TEVAR, and 7 BEVAR procedures. In 14 patients (70%), aneurysm disease was associated with symptomatic aorto-iliac occlusive disease (AIOD), with Rutherford class III to IV. The PACSS was grade IV in 89% of the cases and the CASS (mean 14±2) was grade III to IV in all cases. The stent-graft (SG) outer diameter (5.60±1.65 mm) was significantly larger by 50% than MLD (3.96±1.20 mm), with an SG/MLD index of 1.50±0.51 (p<0.001). Technical success was 100%. No dissection, rupture, or distal embolization occurred. One (3.4%) bail-out stenting was necessary as endoconduit after IVL treatment. One month CTA showed that postoperative luminal gain increased by 93% (p<0.001). An improvement of 2 Rutherford classes occurred in all AIOD patients with a primary patency of 100% at last follow-up. This study shows the safety and feasibility of IVL as a valuable option to treat narrow and calcified iliac arteries to facilitate endograft delivery. Further studies will be useful to confirm these results. In this article, the use of intravascular iliac artery lithotripsy to facilitate aortic endograft delivery is explored. The presence of iliac severe calcifications still represents a contraindication for aortic endovascular repair. Intravascular lithotripsy increases the feasibility and safety of endovascular aortic procedures, facilitating endograft delivery and reducing the risk of iliac rupture and/or dissections by improving vessel compliance and luminal gain. This novel vessel preparation could be an alternative to "paving and cracking" and/or iliac conduits. This study describes a new score to classify the severity of iliac calcifications, considering anatomical parameters and the profile of aortic endografts delivery system.

Relationship Between Abdominal Aortic Aneurysm and Inflammatory Markers

Objective: In this study, we aimed to investigate the relationship between abdominal aortic aneurysm and systemic immune inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and other inflammatory markers, especially those derived from complete blood count. &#x0D; Methods: Retrospectively, 72 consecutive patients admitted to our clinic for Abdominal Endovascular Aneurysm Repair (EVAR) for abdominal aortic aneurysm (AAA) between January 2019 and January 2022 were included in the study. Routine blood samples were taken before EVAR operation. NLR, PLR, SII of the patients were calculated and, RDW, Mean Platelet Volume (MPV), C-reactive protein values and other laboratory tests were recorded. They were compared with an age-matched control group.&#x0D; Results: The age of the patients included in the study was 67.7 ± 10.6 years and the majority were male. The frequency of hypertension and coronary artery disease was also higher. In the comparison of hematologic parameters with the control group, MPV was 10.4(9.6-11.2) versus 9.5(8.6-10.1), p

Side branch embolization before endovascular abdominal aortic aneurysm repair to prevent type II endoleak: A prospective multicenter study

PurposeThe purpose of the study was to evaluate the efficacy and safety of pre-emptive transcatheter arterial embolization (P-TAE) of aortic side branches to prevent type II endoleak in patients with abdominal aortic aneurysm after endovascular abdominal aneurysm repair (EVAR). Materials and methodsThis multicenter, prospective, single-arm trial enrolled 100 patients with abdominal aortic aneurysm from nine hospitals between 2018 and 2021. There were 85 men and 15 women, with a mean age of 79.6 ± 6.0 (standard deviation) years (range: 65–97 years). P-TAE was attempted for patent aortic side branches, including the inferior mesenteric artery, lumbar arteries, and other branches. The primary endpoint was late type II endoleak incidence at 6 months post-repair. Secondary endpoints included changes in aneurysmal sac diameter at 6- and 12 months, complications, re-intervention, and aneurysm-related mortality. Aneurysm sac changes at 6- and 12 months was compared between the late and no-late type II endoleak groups. ResultsCoil embolization was successful in 80.9% (321/397) of patent aortic side branches, including 86.3% of the inferior mesenteric arteries, 80.3% of lumbar arteries, and 55.6% of other branches without severe adverse events. Late type II endoleak incidence at 6 months was 8.9% (8/90; 95% confidence interval: 3.9–16.8%). Aneurysm sac shrinkage > 5 mm was observed in 41.1% (37/90) and 55.3% (47/85) of the patients at 6- and 12-months post-EVAR, respectively. Patients with late type II endoleak had less aneurysm sac shrinkage than those without type II endoleak at 12 months (˗0.2 mm vs. ˗6.0 mm; P = 0.040). No patients required re-intervention for type II endoleak, and no aneurysm-related mortalities occurred. ConclusionP-TAE is safe and effective in preventing type II endoleak, leading to early sac shrinkage at 12 months following EVAR.

How does totally percutaneous femoral artery access compare with surgical cut-down femoral artery access for adults undergoing elective bifurcated abdominal endovascular aneurysm repair?

How does totally percutaneous femoral artery access compare with surgical cut-down femoral artery access for adults undergoing elective bifurcated abdominal endovascular aneurysm repair?

Impact of the endovascular revolution on vascular training through analysis of national data case reports

BackgroundIn the last couple of decades, there has been a shift in use of endovascular procedures in vascular surgery. We aim to examine the impact of this endovascular shift on vascular trainees, determine whether the surgical experiences of trainees in the integrated residency and fellowship program changed over time, and identify differences between the two training paradigms. MethodsData were extracted from the Accreditation Council for Graduate Medical Education National Data Case Logs for the vascular surgery fellowship (1999-2021) and integrated residency (2012-2021) programs. Every procedure was categorized as open or endovascular, then designated into the following subcategories: thoracic aneurysm repairs, cerebrovascular, abdominal aneurysm repairs, venous, vascular access, peripheral arterial disease, visceral, or miscellaneous. We compared the prevalence of open and endovascular cases in the fellowship and integrated residency using data from overlapping years (2012-2021). In addition, we compared the mean number of cases per trainee per year within designated time intervals. The vascular surgery fellowship was grouped into three intervals: 1999 to 2006, 2006 to 2013, and 2013 to 2021; the integrated vascular surgery residency was grouped into two intervals: 2012 to 2017 and 2017 to 2021. Data were standardized to represent the average number of cases per trainee per year. ResultsWithin the fellowship, we found a 362.37% increase in endovascular procedures (mean, 56.80 ± 32.57 vs 262.63 ± 9.91; P < .001), although there was only a 32.47% increase in open procedures (220.19 ± 4.55 vs 291.68 ± 8.20) between the first and last time intervals. There was a decrease in abdominal aneurysm repair (24.46 ± 7.30 vs 13.85 ± 0.58; P < .001) and visceral (6.41 ± 0.44 vs 5.80 ± 0.42; P = .039) open procedures. For the integrated residency, there was an increase in open procedures by 8.52% (352.18 ± 8.23 vs 382.20 ± 5.84; P < .001). Residents had greater total, open, and endovascular procedures per year than fellows (all P < .001). Chief residents had approximately one-half as many cases as vascular fellows per year. Fellows performed more open abdominal aneurysm repair (14.04 ± 0.80 vs 12.40 ± 1.32; P = .007) and visceral (5.83 ± 0.41 vs 4.88 ± 0.46; P > .001) procedures than residents. Overall, 52% to 53% of cases performed by trainees per year were open procedures in both the fellowship and integrated residency (288.56 ± 12.10 vs 261.27 ± 10.13, 365.52 ± 17.23 vs 319.58 ± 6.62; both P < .001). Within the subcategories, only cerebrovascular, vascular access, and miscellaneous had more open procedures performed per trainee. ConclusionsVascular surgery training has incorporated new endovascular techniques and technologies while maintaining operative training in open procedures. Despite changes in vascular surgery training, trainees are still performing more open procedures than endovascular procedures per year. However, there are evolving deficits in specific types of procedures.

Hypnosis during Endovascular Abdominal Aortic Aneurysm Repair.

(1) Background: Endovascular abdominal aneurysm repair (EVAR) is associated with a reduction in early morbidity and mortality compared with open repair. Procedures performed under hypnosis might represent an alternative to further reduce the risks related to general anesthesia (GA). This study aimed to assess the feasibility and safety of hypnosis and local anesthesia during EVAR. (2) Methods: All consecutive patients who underwent EVAR or fenestrated/branched EVAR (f/bEVAR) under hypnosis and local anesthesia (n = 28) between 2017 and 2019 were retrospectively studied and matched to control patients who underwent the same interventions under GA. (3) Results: There was neither a significant difference in the length of ICU stay (p = 0.06), nor in the occurrence of endoleaks, reintervention, and 30-day mortality rate (p = 1.00, 0.73, and 0.24, respectively). The hypnosis group had lower use of norepinephrine (maximum dose 0.04 ± 0.1 vs. 1.2 ± 4.0 mg·h-1, p < 0.001), shorter procedure duration (181.2 ± 71.4 vs. 214.3 ± 79.6 h, p = 0.04), and shorter length of stay (5.4 ± 3.2 vs. 8.4 ± 5.9 days, p = 0.002). (4) Conclusions: In this pioneering study, hypnosis during EVAR appears feasible and safe. It is associated with lower intraoperative use of norepinephrine, as well as procedure duration and length of in-hospital stay.

A study of mortality frequency and clinical course of postoperative renal and abdominal visceral complications following open aortic surgery for abdominal aortic aneurysm requiring supra renal aortic cross-clamp

ABSTRACT Background: Endovascular interventions for abdominal aortic aneurysms (AAAs) are fast evolving; however, due to higher rates of reintervention and no survival benefits after 2 years, open surgical procedures are pivotal. Here, we present mortality and morbidity analysis of open surgical procedures requiring suprarenal cross clamping for AAA repair. Materials and Methods: The present study is a retrospective hospital record-based study selecting 34 cases that required suprarenal cross-clamping out of 200 abdominal aortic aneurysm surgeries. Out of the total 34 patients, 22 (64.7%) were males and 12 (35.3%) were females. The mean age of all participants was 58.05 years (with an 8.1 standard deviation). Out of 34 cases, 20 cases (58.8%) were classified as suprarenal and pararenal aneurysms and 14 cases were juxtarenal aneurysms (41.2%). Out of the 14 juxtrarenal aneurysm cases, 7 (50%) were atherosclerotic and 2 (14.3%) were Marfan’s Syndrome, while inflammatory were 2 (14.3%) and infected were 2 (14.3%) and 1 was a case of Takayasu’s arteritis (7.1%). Mortality and morbidity, including renal function decline, need for hemodialysis, acute pancreatitis, and hepatic and gastrointestinal (GI) complications, were recorded as early (up to 30 days) and late (up to 1 year). The results were recorded separately for suprarenal, pararenal, and juxtarenal aneurysm types and presented in that way, which is the highlight of our study. Results: Early mortality occurred in 3/34 (8.8%) cases, where late mortality happened in 2/34 (5.9%) cases, which are exclusive of early mortality cases. Considering the early mortality and complications, 2 out of 4 cases (50.0%) of the suprarenal group died early, renal dysfunction happened in 4/34 cases (11.8%), of which 3 (8.8%) required dialysis. No cases of pancreatitis, while acute liver failure complicated 3 out of 34 (8.8%) cases. GI bleed and mesentric ischemia each complicated 2 out of 34 cases (5.9%). Prolonged ileus was noticed as the most common GI complication complication. Early mortality was highest in the suprarenal group with renal dysfunction. Considering late mortality and complications, 1 out of 16 cases (6.3%) of the pararenal group died late, and 1 out of 14 cases (7.1%) of the juxta renal cases died late. There was no late mortality in the suprarenal group. Renal dysfunction happened in 2/34 cases (5.9%), of which none required dialysis. Complete data have been presented as per the aneurysm type. Conclusions: Patients requiring suprarenal aortic cross-clamping for open surgical repair of abdominal aorta aneurysm are usually high-risk surgical candidates, considering both early and late mortality and morbidity. Early mortality was maximum in the suprarenal group (50.0%), as were postoperative renal dysfunction and hemodialysis requirements. Visceral complications (acute liver failure and GI complications) were also maximum with the suprarenal group. Late mortality was recorded in the pararenal and juxtarenal groups, with renal dysfunction being recorded in the suprarenal and juxtarenal groups. Visceral complications were recorded in both pararenal and juxtarenal groups. One confounding factor could be the high early mortality in the suprarenal group, resulting in less number of survivors for late postoperative recording. Overall, we conclude that suprarenal aortic aneurysms carry the highest burden of early mortality with renal and visceral complications postoperative.

The Semibranch: A New Tool for Complex Aortic Pathologies.

To describe the semibranch as new tool to treat patients with thoracoabdominal, para- and juxtarenal aortic pathologies. The technique is demonstrated in 2 patients with aortic pathologies. First, a 76-year-old woman with a type Ia endoleak after endovascular repair of abdominal aneurysm (EVAR). Due to the short mainbody of the EVAR and suprarenal extension of the pathology, a 4-branched device with integrated bifurcation was chosen. To realize a branched device in small diameters of the suprarenal aorta, 2 semibranches, for the superior mesenteric artery (SMA) and the celiac trunc (CT), were planned. The second patient, a 75-year-old man, had a juxtarenal aneurysm. Due to small diameters of the aorta, semibranches for the SMA and the CT were planned. In both cases, a total transfemoral approach was used with a steerable sheath. Placement, cannulation of the semibranch, forwarding of the bridging stentgraft, and sealing was uneventful. All 4 semibranches were successful in sealing the aneurysm. The semibranch is another tool in the armamentarium of the endovascular interventionalist, which can expand the range of patients that can be treated. Especially patients with small aortic diameter or short distances between target vessels with the same offspring angle can profit from the semibranch design. The semibranch is a new tool to treat thoracoabdominal as well para- and juxtarenal aortic pathologies. Due to its reduced length, packaging density can be higher and diameter of the stentgraft can be larger. It closes the gap in pathologies where fenestration are not suitable (kinked aortas) and there is not enough space for standard inner branches (small diameters).

Perioperative Mortality and the Long-Term Outcome of Endovascular Abdominal Aneurysm Repair (EVAR): A Single-Centre Experience.

Background Abdominal aortic aneurysm (AAA) is a dangerous disorder characterised by abnormal enlargement of the abdominal aorta. The severity of the aneurysm and the presence of symptoms determine the necessary monitoring or treatment to prevent potential fatalities. The objective of this study is to estimate the perioperative mortality and long-term outcome of endovascular abdominal aneurysm repair (EVAR). Patients and methods This is a descriptive, retrospective, observational study. We retrieved the data of the AAA patients who underwent EVAR at Glan Clwyd Hospital from January 2015 to January 2023. The study sample consisted of patients diagnosed with isolated AAA, with or without iliac branch involvement, who were deemed suitable for EVAR based on factors such as advanced age, presence of comorbidities, the complexity of the condition, history of prior surgery, fulfillment of indication criteria, and patient desire. The data was analysed using SPSS statistical software, version 21.0 (IBM Corp., Armonk, NY). Results Two hundred and twenty-two patients were studied. The outcome of the EVAR among the patients was endo-leak 28.4% (n = 63); migration 1.4% (n = 3); blockage 0.5% (n = 1); infolding 0.5% (n = 1); perioperative mortality 1.4% (3); and other complications like access site or acute kidney injury were 1.4% (n = 3). However, no complications were reported in most of the patients, 66.7% (n = 148). Upon evaluating the variables that could affect the outcome, we observed that the ASA grade, comorbidities, and the indication of the intervention had a significant effect on the outcome (P values = 0.000, 0.048, and 0.014, respectively). Conclusion The findings demonstrate that when EVAR is performed by a skilled team adhering to proper criteria, the results are optimal. The mortality rate during the perioperative period was 1.4%. Furthermore, we have shown a satisfactory rate of complications when compared to international data.

Impact of Previous Open Abdominal Surgery on Open Abdominal Aortic Repair: A Study from the NSQIP Database

While endovascular aneurysm repair has become a first-line strategy in many centers, open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) is still the best option for certain patients. A significant number of patients who are offered OSR for AAA have been previously submitted to other open abdominal surgeries (PAS). It is unclear, however, how this may impact their outcomes. The purpose of this study was to determine if there is an association between PAS and outcomes of OSR of AAA. This is a retrospective cohort study based on clinical data from the American College of Surgeons National Surgical Quality Improvement Program database, including all patients undergoing elective OSR for AAA between 2011 and 2017. Excluded were patients with missing data on prior abdominal surgery, supramesenteric clamping, or urgent repairs. Patients with prior abdominal surgery (PAS) and patients without prior abdominal surgeries (nonPAS) were compared. The primary outcome was 30-day postoperative mortality. Secondary outcomes were operating time, ischemic colitis, postoperative complications, and lengths of hospital stay. Of the 2034 patients included, 27% had previous open abdominal surgery and 73% did not. Overall, the median age was 71(interquartile range 65-76), 72% of patients were male, 44% were smokers, and the average body mass index was 27kg/m2. Univariate analysis showed no difference in postoperative 30-day mortality (4.0% PAS vs. 4.1% nonPAS, P=0.91) or overall postoperative complication rates (33% PAS vs. 29% nonPAS, P=0.07). Previous open abdominal surgery was significantly associated with longer operating times (P=0.032) and an almost doubled rate of ischemic colitis (4.7% PAS vs. 2.6% nonPAS, P=0.02). Postoperative intensive care unit and hospitalization were also significantly longer in patients with prior abdominal surgery (P=0.005 and P=0.014, respectively). Finally, there were significantly less patients discharged home, as opposed to institutionalized care (75.7% PAS down from 82.4% nonPAS, P=0.001). Despite these initial univariate analysis results, on multivariate analysis, PAS actually did not prove to be a statistically significant independent risk factor for 30-day mortality, ischemic colitis, or longer operating times. This study suggests that patients who have undergone PAS may have some disadvantages in OSR of AAA. However, these negative trends do not go so far as to statistically significantly identify PAS as an independent risk factor for 30-day mortality, ischemic colitis, or longer operating times. As such, we suggest that a history of previous open abdominal surgery, in and of its own, should not exclude patients from consideration for open aortic abdominal aneurysm repair.

Two-Year Results on Real-World Fenestrated or Branched Endovascular Repair for Complex Aortic Abdominal Aneurysm in France.

To describe and compare mid-term outcomes from 2 real-world data collection efforts on fenestrated and branched endovascular aortic repair (fbEVAR) for complex abdominal aortic aneurysms (AAAs) in France and to evaluate the potential of health care databases for long-term post-market surveillance (PMS) and continued reimbursement approval. Two real-world studies were conducted in France: a retrospective health care database study (SNDS) and a prospective clinical study. In the SNDS study, data from implantation and/or hospital stays occurring during follow-up were extracted for all patients treated with the study devices from April 2012 to December 2018. In the clinical study, high-risk patients undergoing fbEVAR with the study devices were enrolled consecutively at 15 sites in France from December 2016 to November 2018. Data from 1073 patients were extracted from SNDS and compared with analogous variables from 186 patients in the clinical study. Most demographic details were similar between studies (SNDS vs clinical: mean age, 71.9 vs 71.8 years; men, 91.0% vs 89.8%), as was 30-day mortality (SNDS: 5.5%, clinical: 4.3%). Patients received custom-made fenestrated or branched devices (SNDS: 80.7%, clinical: 96.2%) or CE-marked Zenith Fenestrated devices (SNDS: 19.3%, clinical: 3.8%). Initial or technical success was above 94% for both studies. Two-year freedom from all-cause mortality was 80.0% (SNDS) and 85.1% (clinical study). Two-year freedom from aneurysm-related mortality was 93.8% (SNDS) and 94.6% (clinical study). Detailed imaging outcomes were not captured within SNDS; however, information on secondary procedures to restore patency was available and used as a surrogate measure for secondary interventions. Two-year freedom from secondary interventions was 73% for the SNDS study. In the clinical study, at 2 years, aneurysm stability or shrinkage was observed in 92.3% of patients, freedom from target vessel primary patency loss was above 95% for all visceral target vessels, and freedom from secondary interventions was 79.1%. Real-world outcomes from the SNDS and clinical study suggest positive mid-term outcomes in high-risk populations following fbEVAR for complex AAAs. The similarities between these studies suggest that the use of health care databases may be an alternative to prospective clinical studies for long-term follow-up and PMS. Positive results following endovascular repair of complex abdominal aortic aneurysms are observed from data extracted from both the French health care database and a post-market clinical study despite initial high-risk patient status and diverse center experience. These outcomes parallel more rigorously designed studies and suggest that with careful study design, real-world data collections have high translatable value to add to the clinical understanding of fenestrated and branched endovascular aortic repair (fbEVAR).