Outcomes Of Endovascular Aneurysm Repair Research Articles

Prior abdominal surgery is not associated with 30-day mortality or morbidities after endovascular repair of complex abdominal aortic aneurysm.

Prior abdominal surgery (PAS) has the potential to affect outcomes of abdominal aortic aneurysm (AAA) repair. Recently, endovascular aneurysm repair (EVAR) has been expanded among patients with complex AAA, which involves visceral branches in the upper abdominal aortic. However, outcomes of EVAR for complex AAA in patients with PAS have not been examined. This study aimed to investigate the impact of PAS on 30-day outcomes in EVAR for complex AAA. Patients who underwent EVAR for complex AAA were identified in ACS-NSQIP targeted database from 2012 to 2022. Complex AAA was defined as juxtarenal, suprarenal, or pararenal proximal extent, Type IV thoracoabdominal aneurysm, or aneurysms treated with Zenith Fenestrated endograft. Patients with age less than 18 years, ruptured AAA with or without hypotension, acute intraoperative conversion to open, and emergency presentation were excluded. Multivariable logistic regression was used to compare 30-day postoperative outcomes of patients with and without PAS. Demographics, baseline characteristics, aneurysm diameter, indication for surgery, proximal and distant aneurysm extent, anesthesia, and concomitant procedures were adjusted. There were 515 (28.34%) and 1302 (71.66%) patients with and without PAS, respectively, who underwent EVAR for complex AAA. Patients with and without PAS had comparable 30-day mortality (3.11% vs 3.00%, aOR = 0.766, 95 CI = 0.407-1.442, p = .41). Organ system complications including cardiac complications, stroke, pulmonary complications, and renal complications were comparable between patients with and without PAS. All other 30-day outcomes were similar between groups. However, patients with PAS had higher 30-day readmission rate (11.65% vs 7.14%, aOR = 1.634, 95 CI = 1.145-2.331, p = .01). While PAS has high prevalence among patients undergoing EVAR for complex AAA, it does not impact 30-day mortality and morbidities. Thus, EVAR for complex AAA can be considered safe for patients with PAS in terms of short-term outcomes, despite the long-term prognosis in these patients being needed in further studies.

Midterm outcomes of endovascular repair for abdominal aortic aneurysm using the cuff-first technique to prevent type II endoleaks

ObjectiveThe aim of this study was to evaluate the initial and midterm outcomes of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) using the cuff-first technique (CFT) to prevent type II endoleak (T2EL). MethodsCFT involves deploying an aortic cuff inside the AAA to cover the ostium of the aortic side branch vessels before deploying the main body. We performed a retrospective review of all patients undergoing EVAR with CFT or side branch embolization (SBE) for AAAs at The Jikei University Hospital between 2016 and 2022. Primary endpoint was the rate of aneurysm sac shrinkage. Secondary endpoints were procedure time, radiation exposure, technical and clinical success rates, occurrence of T2EL, and freedom from reintervention or aneurysm-related death. ResultsOf 406 patients who underwent EVAR for AAAs, CFT was utilized in 56 (CFT group) and SBE in 35 (SBE group); all 91 patients were included in this study. There were no differences in patient demographics between groups, but there were differences in patency rate of the inferior mesenteric artery and absent intraluminal thrombus. The technical success rate per target vessel in the CFT and SBE group was 97.8% and 91.8%, and the clinical success rate was 91.0% and 100%, respectively. The median procedure time was shorter for CFT than for SBE: CFT, 10 (interquartile range [IQR], 6-14) minutes vs SBE, 25 (IQR, 18.5-45) minutes; P < .05), and median radiation exposure was lower for CFT than for SBE (CFT, 1455 (IQR, 840-2634) mGy vs SBE, 2353 (IQR, 1552-3586) mGy; P < .05). During the median follow-up of 25 months (IQR, 12.5-47 months), sac shrinkage occurred at similar rates in both groups (CFT, 37.5% vs SBE, 40.0%; P = .812), and there were no differences in freedom from reintervention (CFT, 96.2% and 91.4% at 12 and 36 months vs SBE, 100% and 89.5% at 12 and 36 months; log-rank P = .761) and freedom from aneurysm-related death (100% at 36 months in both groups; log-rank P = .440). The odds ratio of CFT vs SBE for sac regression was calculated by adjusting for inferior mesenteric artery patency and absent intraluminal thrombus, resulting in no statistical significance (odds ratio, 1.231; 95% confidence interval, 0.486-3.122). ConclusionsCFT is feasible with a shorter procedure time and lower radiation exposure than SBE and comparable mid-term outcomes, including sac shrinkage rate, compared with SBE. We believe that CFT, if anatomically suitable, is an alternative to SBE for the prevention of T2EL during EVAR.

Early and midterm outcomes of EVAR with 34 and 36 mm large endograft sizes: A single tertiary center study

Aim: Endovascular aneurysm repair (EVAR) has become a preferred method for accessing anatomically suitable abdominal aortic aneurysms in recent years. Advances in techniques and materials have led to the management of more challenging cases. Anatomical difficulties in the structure of the aneurysm neck can adversely affect the success of the procedure. In this study, we aimed to evaluate early and midterm outcomes in patients with wide-necked infrarenal abdominal aortic aneurysms treated with 34 mm or 36 mm EVAR endografts. Material and Methods: We evaluated infrarenal abdominal aortic aneurysms treated with 34 mm or 36 mm long EVAR allografts between January 2019 and January 2023 at Ankara Bilkent City Hospital Cardiovascular Surgery Clinic. We included and assessed patients with a neck diameter of 28 mm or greater using follow-up computed tomography angiography (CTA). We evaluated early and midterm morbidity and mortality as well as endovascular complications such as endoleak or migration. Results: A total of 58 patients with wide-neck infrarenal abdominal aortic aneurysms underwent 34 mm or 36 mm EVAR endograft deployment. There was no early mortality. The mean follow-up period was 21.7±6.4 months. Eight patients were found to have endoleaks—four had type 2 endoleaks, two had type 1b endoleaks, one had type 3 endoleak and one had type 1a endoleak. Except for type 2 endoleaks, all patients underwent endovascular reintervention. Conclusion: Our study demonstrated the successful application of 34 mm or 36 mm long endografts to patients with abdominal aortic aneurysms with a wide neck diameter. Regarding the midterm outcomes, standard EVAR procedures with large endografts are feasible and have successful outcomes.

The impact of endovascular stents types on perioperative outcomes of ruptured abdominal aortic aneurysms: a single-center experience.

Ruptured abdominal aortic aneurysm (rAAA) represents a critically urgent vascular surgical condition, and endovascular aneurysm repair (EVAR) is a clinically effective treatment option. This study aims to investigate whether the type of intravascular graft used for ruptured abdominal aortic aneurysms has an impact on perioperative outcomes of EVAR. A retrospective analysis was conducted on patients who underwent EVAR for ruptured abdominal aortic aneurysm at a single medical center from 2019 to 2022. Patients who required simultaneous stent implantation in the renal arteries or visceral arteries, as well as those with ruptured aneurysms located in the para-renal, supra-renal, or thoracoabdominal regions, were excluded from the analysis. Additionally, patients who underwent open surgery during the initial procedure or converted to open repair were excluded. The primary endpoint was perioperative mortality rate. Other study outcomes included perioperative complications, reoperation rates, and length of hospital stay. Characteristics and corresponding outcomes of patients receiving different endovascular stent treatments were compared using SPSS software. A total of 58 patients received treatment with two types of endovascular stents: Gore Excluder (n = 29) and Microport Hercules (n = 29). The number of other endografts was too small for statistical analysis. Compared to patients treated with Hercules, those treated with Excluder had a significantly increased likelihood of concomitant coronary atherosclerosis (P = 0.009) and potentially higher creatinine levels (P = 0.014). Additionally, Excluder was more commonly used in patients with shorter aneurysm necks (P < 0.001). There was a statistically significant difference in overall mortality between the two groups (Hercules 27.6%, Excluder 6.9%, P = 0.037). Furthermore, patients who received Excluder treatment had lower mortality rates in subgroups of non-alcohol users (P = 0.028), non-diabetic patients (P = 0.027), and patients with dispersed thrombosis at the proximal neck (P = 0.046). In the multivariate analysis, the type of stent used (OR 0.06, 95% CI 0.00-1.31) and the occurrence of intraoperative complications (OR 20.70, 95% CI 1.14-76.70) in patients with rAAA was identified as an independent risk factor for perioperative mortality. Our study suggests that the management of intraoperative complications may be a modifiable factor that can improve outcomes. Patients receiving Excluder treatment demonstrated better performance in EVAR for single-center rAAA patients compared to other endovascular stents, and this difference warrants further investigation.

Long Term Outcomes of the Gore Excluder Low Permeability Endoprosthesis for the Treatment of Infrarenal Aortic Aneurysms

This study evaluated the long term outcomes of endovascular aneurysm repair using the Gore Excluder Low Permeability (LP) endoprosthesis across high volume Dutch hospitals. A retrospective analysis was conducted of patients treated with the Excluder LP for infrarenal abdominal aortic aneurysm (AAA) in four hospitals between 2004 - 2017. Primary outcomes were overall survival, freedom from re-interventions (overall, inside/outside instructions for use, IFU), and AAA sac dynamics: growth (> 5 mm), stabilisation, and regression (< 5 mm). Secondary outcomes were technical success (device deployment), procedural parameters, and re-interventions. Follow up visits were extracted from patient files, with imaging assessed for complications and AAA diameter. A total of 514 patients were enrolled, with a median (IQR) follow up of 5.0 (2.9, 6.9) years. Survival rates were 94.0% at 1 year, 73.0% at 5 years, and 37.0% at 10 years of follow up, with freedom from re-interventions of 89.0%, 79.0%, and 71.0%, respectively. Treatment outside IFU was 37.9%, leading to significantly more re-interventions over 10 years compared with inside IFU (36.0% vs. 25.0%, respectively; p = .044). The aneurysm sac regressed by 53.5% at 1 year, 65.8% at 5 years, and 77.8% at 10 years, and grew by 9.8%, 14.3%, and 22.2%, respectively. Patients with 1 year sac growth had significantly worse survival (p = .047). Seven patients (1.4%) had a ruptured aneurysm during follow up. Over 15 years, endoleak type 1a occurred in 5.3%, type 1b in 3.1%, type 3 in 1.9%, type 4 in 0.2%, and type 2 in 35.6% of patients. This multicentre study of real-world endovascular aneurysm repair data utilising the Gore Excluder LP endoprosthesis demonstrated robust long term survival and re-intervention rates, despite 37.9% of patients being treated outside IFU, with type 4 endoleak being rare. Treatment outside IFU significantly increased re-intervention rates and 1 year sac growth was associated with statistically significantly worse survival.

Locoregional Anesthesia Has Lower Risks of Cardiac Complications Than General Anesthesia After Prolonged Endovascular Repair of Abdominal Aortic Aneurysms

ObjectivesWhile general anesthesia is the primary anesthesia in endovascular aneurysm repair (EVAR), some studies suggested locoregional anesthesia could be a feasible alternative for eligible patients. However, most evidence was from retrospective studies and was subjected to an inherent selection bias that general anesthesia is often chosen for more complex and prolonged cases. To mitigate this selection bias, this study aimed to compare 30-day outcomes of prolonged non-emergent intact infrarenal EVAR in patients undergoing locoregional or general anesthesia. In addition, risk factors associated with prolonged operative time in EVAR were identified. Designretrospective large-scale national registry study. SettingAmerican College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted database from 2012-2022 Participants4075 out of 16,438 (24.79%) patients had prolonged EVAR. Among patients with prolonged EVAR, 324 (7.95%) were under locoregional anesthesia. There were 3,751 (92.05%) under general anesthesia, where 955 of them were matched to the locoregional anesthesia cohort. InterventionsPatients undergoing infrarenal EVAR were included. Exclusion criteria included age<18 years, emergency cases, ruptured AAA, and acute intraoperative conversion to open. Only cases with prolonged operative times (>157 minutes) were selected. A 1:3 propensity-score matching was used to address demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, and concomitant procedures between patients under locoregional and general anesthesia. Thirty-day postoperative outcomes were assessed. Moreover, factors associated with prolonged EVAR were identified by multivariable logistic regression. Measurements and Main ResultsExcept for general anesthesia contraindications, patients undergoing locoregional or general anesthesia exhibited largely similar preoperative characteristics. After propensity-score matching, patients under locoregional and general anesthesia had a lower risk of myocardial infarction (0.93% vs 2.83%, p=0.04) but comparable 30-day mortality (3.72% vs 2.72%, p=0.35) and other complications. Specific concomitant procedures, aneurysm anatomy, and comorbidities associated with prolonged EVAR were identified. ConclusionsLocoregional anesthesia can be a safe and effective alternative to general anesthesia, particularly in EVAR cases with anticipated complexity and prolonged operative times, as it offers the potential benefit of reduced cardiac complications. Risk factors associated with prolonged EVAR can aid in preoperative risk stratification and inform the decision-making process regarding anesthesia choice.

Long-Term Outcomes of Endovascular Repair Within and Outside the Instructions for Use in Korean Patients With Abdominal Aortic Aneurysm.

Endovascular aneurysm repair (EVAR) has been used worldwide to treat abdominal aortic aneurysms (AAAs). Outcomes after EVAR within and outside the instruction for use (IFU) remain controversial. We analyzed long-term outcomes of EVAR within-the-IFU compared with that outside-the-IFU and baseline clinical/anatomical characteristics that influence outcomes of EVAR. The study included 546 patients who underwent EVAR for infrarenal AAA from 1997 to 2021 at 2 Korean medical centers. The primary endpoint was graft-related adverse events (GRAEs), including type 1 or 3 endoleak, reintervention (included open conversion), aneurysm sac enlargement, aneurysm-related mortality (ARM), rupture, stent-graft migration, and stent thrombotic occlusion. The patients who underwent EVAR outside the IFU were 287 (52.6%). A neck angle of >60° was most common outside the IFU criteria (n=146, 50.9%). This study revealed that patients outside the IFU had a higher rate of GRAEs compared with patients within the IFU (hazard ratio [HR]: 1.879; 95% confidence interval [CI]: 1.045-2.386). A neck angle of >60° was a significant risk factor for GRAEs (adjusted HR: 2.229; 95% CI: 1.418-3.503), type 1 or 3 endoleak (adjusted HR: 2.640; 95% CI: 1.343-5.189), and reintervention (adjusted HR: 1.891; 95% CI: 1.055-3.388). Our study revealed EVAR with outside the IFU was associated with increased GRAEs, mainly attributed to endoleak and ARM, compared with EVAR with within the IFU. In addition, severe neck angulation was an independent risk factor for GRAEs, type 1 or 3 endoleak, and reintervention. Our study revealed endovascular aneurysm repair (EVAR) with outside-the-instruction for use (IFU) was associated with increased graft-related adverse events (GRAEs) compared with EVAR with within-the-IFU. In the low-risk population, the incidence of GRAEs and Aneurysm related mortality were higher in the outside-the-IFU group rather than within-the-IFU group. In addition, severe neck angulation was an independent risk factor for GRAEs, type 1 or 3 endoleak and reintervention.

Procedural and long-term outcomes of elective endovascular abdominal aortic aneurysm repair in octogenarians

The aim of the study was to compare the immediate and long-term outcomes of endovascular aneurysm repair (EVAR) between patients under and over the age of 80 with abdominal aortic aneurysm (AAA). From 2011 to 2017, we conducted a retrospective cohort study with AAA patients who received elective EVAR. Primary outcomes included hospital mortality, length of stay, acute kidney injury, and the need for re-interventions. Secondary outcomes included aneurysm-related mortality, acute myocardial infarction, stroke, acute limb ischemia, and prolonged mechanical ventilation. A total of 77 (62.6%) patients under the age of 80 years old and 46 (37.4%) octogenarians were included in the study. The male gender and AAA diameter did not differ among groups (92.2% vs. 82.6%, p = 0.11 and 5.4 cm [4.9-6.2 cm] vs. 5.4 cm [5-6 cm], p = 0.53, respectively). The younger patients had a higher prevalence of tobacco use (72.7% vs. 41.7%, p = 0.01). There were no deaths during the index hospitalization. The incidence of reinterventions (5.3% vs. 15.2%, p = 0.11) and acute kidney injury (14.3% vs. 23.9%, p = 0.18) did not differ between groups, but the length of stay was longer for octogenarian patients (3 days [2-4] vs. 2 days [2-3, p = 0.04)]. Endoleaks were the most common cause for re-interventions (81.8%), with a prevalence of 34% across the entire cohort. There were no differences in any of the secondary outcomes between groups. In octogenarian patients with AAA, EVAR represents a safe procedure both during the index hospitalization and during long-term follow-up.

Long-Term Outcomes of Endovascular Aneurysm Repair in Patients Aged ≤70 Years.

Objectives: The efficacy of endovascular aneurysm repair (EVAR) against abdominal aortic aneurysm (AAA) in younger patients remains unknown. Hence, the current study aimed to investigate whether the aneurysm-related mortality rate of EVAR is acceptable among patients aged ≤70 years. Methods: Among 644 patients, 148 underwent EVAR (EVAR group), and 496 received open surgical repair (OSR group). The cumulative incidence rates of aneurysm-related death, any intervention, and serious aneurysm-related events after AAA repair were evaluated using the cumulative incidence function in the presence of competing risks. Results: The EVAR group had higher prevalences of several comorbidities, and overall survival for the EVAR group was significantly inferior to that of the OSR group. The cumulative incidence rates of aneurysm-related death, any intervention, and serious aneurysm-related events at 5 years were 1.5%, 11.7%, and 6.4% in the EVAR group and 1.3%, 5.3%, and 5.9% in the OSR group, respectively. EVAR was not a significant prognostic factor of aneurysm-related mortality and serious aneurysm-related events. However, it was an independent poor prognostic factor of any intervention. Conclusion: EVAR was not a significant prognostic factor of aneurysm-related mortality and serious aneurysm-related events. Therefore, it demonstrated acceptable procedure-related long-term outcomes, at least in high-risk young patients.

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

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

The impact of large proximal aortic neck on endovascular aneurysm repair outcomes

Background: This study aims to investigate the effect of large proximal aortic neck diameter on post-endovascular aneurysm repair clinical outcomes. Methods: A total of 180 patients (168 males, 12 females; mean age: 69.9±7.4 years; range, 46 to 88 years) who underwent elective endovascular aneurysm repair between June 2016 and September 2021 were retrospectively analyzed. According to the proximal infrarenal aortic neck diameter, the patients were divided into two groups: Group 1 (&lt;25 mm; normal aortic neck) and Group 2 (≥25 mm; pre-aneurysmatic aortic neck). Patient characteristics, proximal infrarenal aortic neck diameter measurements with computed tomography angiography, and clinical outcomes were recorded. The primary endpoint was to assess post-endovascular aneurysm repair aortic neck dilatation, mortality, endoleaks, overall survival, type 1a endoleaks-free survival, and eventfree survival regarding the groups. Results: There was no statistically significant difference in early mortality (p=0.55) and type 1a endoleak incidence between the groups (p=0.55). In Group 1, the mean change in diameter A (proximal infrarenal level) was 2.89±1.74 mm (p=0.01), and it was 2.31±2.1 mm in diameter B (proximal pre-aneurysm-sac level) (p=0.01). The mean change in Group 2 was 2.8±3.4 mm for diameter A (p&lt;0.01) and 2.22±2.3 mm for diameter B (p&lt;0.01). Aortic neck dilatation rates were similar between the groups (p=0.82 for diameter A; p=0.78 for diameter B). The five-year survival, event-free survival, and type 1a endoleak-free survival were also similar (p=0.54, p=0.26, p=0.24, respectively). Conclusion: Our study results showed that patients with &lt;25 mm and ≥25-mm aortic neck diameters had similar mid-term results and aortic neck dilatation ratio. Endovascular aneurysm repair outcomes can be improved with careful patient and graft selection, and early intervention for complications.

Early and Midterm Outcomes of Endovascular Aneurysm Repair With Zenith Alpha Abdominal Stent-Graft: Results From a Multicenter Retrospective Tuscany Registry.

Zenith Alpha Abdominal (Cook Medical, Bloomington, IN, USA) is one of the new-generation low-profile stent-grafts with demonstrated satisfactory early and midterm clinical outcomes for endovascular treatment of abdominal aortic aneurysms (AAAs). The aim was to evaluate early and midterm results of this device in the framework of a multicenter regional retrospective registry, with the analysis of morphological factors affecting outcomes, including different limb configurations. Between January 2016 and November 2021, 202 patients with AAA underwent elective endovascular aneurysm repair (EVAR) with implantation of a Zenith Alpha Abdominal in 7 centers. Early (30 day) outcomes in terms of technical and clinical success were assessed. Estimated 5 year outcomes were evaluated in terms of survival, freedom from type I/III endoleak, freedom from surgical conversion, freedom from limb graft occlusion, freedom from any device-related reintervention, and graft infection evaluation by life-table analysis (Kaplan-Meier test). A comparative analysis between different limb configurations (Zenith Spiral Z AAA iliac legs, codes ZISL vs ZSLE) was performed in terms of limb graft occlusion. The 30 day technical and clinical success rates were 97.5% and 99.5%, respectively. Median follow-up period was 25.5 months (interquartile range [IQR]: 12-43.25). The 5 year survival rate was 73.6%. The estimated 5 year outcomes in terms of freedom from type I/III endoleak, freedom from surgical conversion, freedom from limb graft occlusion, freedom from any device-related reintervention, and freedom from graft infection were 88.6% (95% CI [confidence interval]: 83.4%-93.1%), 95.8% (95% CI: 92.7%-97.1%), 93.6% (95% CI: 90.2%-96.8%), 87% (95% CI: 83.3%-91.6%), and 97.7% (95% CI: 95.1%-98.9%), respectively. About limb configuration, no differences were found in terms of 5 year freedom from limb graft occlusion (ZSLE 93.4% [95% CI: 89.8%-95.5%] vs ZISL 94.3% [95% CI: 90.1%-95.9%], p=0.342; log-rank 0.903). Zenith Alpha Abdominal in elective EVAR offered satisfactory early and 5 year outcomes with low complication rates. Limb graft occlusion continued to be an issue. Limb configuration did not affect outcomes. The authors describe satisfactory early and 5 year outcomes of Zenith Alpha Abdominal in elective endovascular aortic repair in the framework of a multicenter regional retrospective registry. At 5 years freedom from type I endoleak was 88.6%, and rate of endograft infections and conversions to open repair were very low. in the present study. Hot topic about about Zenith stent-graft still remains the limb graft occlusion with a 30-day overall rate of 2%, and estimated 5-year freedom from limb graft occlusion of 93.6%. Limb graft configuration did not affect limb graft occlusion rate. A standardized protocol including iliac stenting should be adopted to reduce kimb graft occlusion.

Five-year results of the LEOPARD trial of commercially available endografts

ObjectiveThe LEOPARD (Looking at EVAR Outcomes by Primary Analysis of Randomized Data) trial is a randomized controlled trial comparing the outcomes of endovascular aneurysm repair (EVAR) using commercially available devices in a real-world population. MethodsA prospective, randomized, multi-center trial was performed to compare the anatomically fixated (AF) AFX/AFX2 endograft system (Endologix) with endografts with proximal fixation (PF) (Cook Medical Zenith Flex; Gore Excluder; and Medtronic Endurant II) in patients with infrarenal abdominal aortic aneurysms. The primary endpoint was freedom from aneurysm-related complications (ARCs), a composite endpoint consisting of perioperative death (≤30 days), aneurysm rupture, conversion to open surgical repair, postoperative endoleaks, endograft migration (≥10 mm), aneurysm enlargement (≥5 mm), endograft limb occlusion, and device- or aneurysm-related reintervention. ResultsThe study population was 455 patients enrolled at 56 United States centers: 235 patients were treated with AF devices and 220 with PF devices. The primary endpoint supported noninferiority of the AF cohort at 1 year. The 5-year freedom from ARC Kaplan-Meier estimates were 63.8% for AF patients and 55.5% for PF patients (P = .10). Kaplan-Meier estimates for freedom from aneurysm-related mortality were 98.7% and 97.0% in the AF group and 99.5% and 98.5% in the PF group at 1 and 5 years. There was no difference in aneurysm-related mortality, all-cause mortality, rupture, secondary interventions, and type I and type III endoleak between the two cohorts. The type III endoleak rate at 5 years for the AFX cohort was 1.5% and 0.0% for the comparator cohort (P = .11). There was a lower type II endoleak rate in the AF group at 5 years (78.8% vs 68.4%; P = .037). There were zero open surgical conversions (0.0%) in the AF group and four (2.0%) in the PF group. ConclusionsThe 5-year results from the LEOPARD study demonstrated that there was no clinically significant difference in overall aneurysm-related outcomes between patients randomized to the AFX endograft system or commercially available endografts with proximal fixation.

Fibrin Glue Sac Filling for Preventing Type II Endoleak, Short-Term Outcomes of a Prospective Randomized Controlled Trial.

Type II endoleak (T2EL) worsens the long-term results of endovascular aneurysm repair (EVAR). How to prevent T2ELs remains controversial. This study aimed to evaluate the efficacy and safety of fibrin glue sac filling (FGSF) to prevent T2ELs after EVAR. A prospective randomized controlled trial was conducted. Patients were randomly divided into group A (standard EVAR + FGSF) and group B (standard EVAR). The follow-up plans included outpatient or telephone consultation at 1 and 3 months and computed tomography (CT) angiography at 6 months, 1 year, and once a year after EVAR. A total of 64 abdominal aortic aneurysm (AAA) patients were randomized to the 2 groups. All patients were followed up for more than 6 months. The 2 groups showed similar baseline characteristics. The rate of T2ELs on immediate angiography in group A (9.6%) was significantly lower than that in group B (33.3%, p=0.033). Moreover, the sac area change was significantly reduced in group A at 6 months after EVAR (p=0.021). However, T2EL incidence was similar at the 6-month (p=0.055) and 1-year (p=0.057) follow-ups, and AAA diameter change was also similar at 1 year. There were similar operation times, radiation doses, severe adverse events (SAEs), and reinterventions between the 2 groups. Fibrin glue sac filling could prevent short-term type II endoleaks and promote AAA shrinkage after 6 months. The FGSF procedure is swift and straightforward; however, patients are at risk of bowel ischemia, especially after previous bowel resections or concomitant superior mesenteric artery (SMA) disease. Standard endovascular aneurysm repair (EVAR) couldn't prevent type II endoleak (T2EL). In this study, we found fibrin glue sac filling (FGSF) could prevent T2EL and promote AAA shrinkage in a short term. And the FGSF procedure is easy, it will be a useful supplement to standard EVAR for clinicians. And FGSF might have potential usefulness on ruptured aneurysms, although without direct evidence.Fibrin glue is often used to hemostasis and tissue adhesion in surgical patients and burn patients, we firstly carry out a randomized controlled study and prove that fibrin glue sac filling could prevent T2EL and promote sac remodeling.

Comparative Outcomes of Endovascular Aneurysm Repair with Open Enterorrhaphy and Traditional Surgery in Management of Aortoenteric Fistula

Comparative Outcomes of Endovascular Aneurysm Repair with Open Enterorrhaphy and Traditional Surgery in Management of Aortoenteric Fistula

Treatment Outcomes of Patients With Ruptured Abdominal Aortic Aneurysms.

Ruptured abdominal aortic aneurysm (rAAA) is a serious complication of abdominal aortic aneurysm associated with high operative mortality and morbidity rates. The present study evaluated the perioperative and long-term outcomes of Korean patients with rAAA based on national health insurance claims data. The National Health Insurance Service (NHIS) database was searched retrospectively to identify patients with rAAA who underwent endovascular aneurysm repair (EVAR) and open surgical repair (OSR) from 2009 to 2018. Perioperative (≤ 30 days), early postoperative (≤ 3 month), and long-term (> 3 month) survival, reinterventions, and complications were assessed. The search identified 1,034 patients with rAAA, including 594 who underwent EVAR and 440 who underwent OSR. When the study period was divided into two, the total numbers of patients with rAAA, patients who underwent EVAR, and octogenarians were higher during the second half. The perioperative mortality rate was 29.8% in the EVAR and 35.0% in the OSR group (P = 0.028). Hartmann's procedure for bowel infarction was performed more frequently in the OSR than in the EVAR group (adjusted odds ratio, 6.28; 95% confidence interval [CI], 2.33-21.84; P = 0.001), but other complication rates did not differ significantly. All-cause mortality during the entire observation period did not differ significantly in the EVAR and OSR groups (adjusted hazard ratio, 1.17; 95% CI, 0.98-1.41; P = 0.087). Abdominal aortic aneurysm-related reintervention rate was significantly lower in the OSR group (adjusted hazard ratio, 0.31; 95% CI, 0.14-0.70; P = 0.005). Although EVAR showed somewhat superior perioperative outcomes for rAAA, the long-term outcomes of EVAR after excluding initial 3 months were significantly worse than OSR. When anatomically feasible for both treatments, the perioperative mortality risk and reasonable prospects of long-term survival should be considered in rAAA.

A Comparison of the Short-Term Outcomes After use of Aorto-Uni-Iliac Versus Bifurcated Endografts for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

To compare short-term outcomes of endovascular aneurysm repair (EVAR) with aorto-uni-iliac (AUI) versus bifurcated (BIFUR) endografts in ruptured abdominal aortic aneurysm (rAAA). A total of 26 rAAA patients receiving EVAR with AUI device (14 patients) or the BIFUR graft (12 patients) between January 2016 and December 2020 were enrolled and reviewed. All EVARs for rAAA were performed in an emergency basis. Graft implantation success, short-term survival rates, and major complications were analyzed. Endograft implantation success was achieved in all patients. AUI group had shorter operative time than BIFUR group (121.77±75.03 vs. 138.45±143.34; P<0.05). The 24-hr and 30-day survival rates were 85.7% (12/14) and 71.4% (10/14), respectively, whereas BIFUR group have 58.3% and 58.3%. None of the rAAA patients in both groups required reintervention. AUI group exhibited less incidence of compartment syndrome and endoleak compared with those of BIFUR ones. The short-term results of EVAR with the AUI configuration graft in patients with rAAAs are encouraging.

Renal outcomes of suprarenal vs. infrarenal endograft fixation in endovascular abdominal aortic aneurysm repair: a narrative review.

Background and ObjectiveAbdominal aortic aneurysm (AAA) is a common pathology with a prevalence of 4.8%. AAA rupture is associated with significant mortality and so early diagnosis followed by regular monitoring is needed until treatment might be considered and plan intervention. Endovascular aneurysm repair (EVAR) is an established and effective alternative to open surgical repair (OSR) in the treatment of AAAs. Key parameters in defining conventional EVAR suitability include the infrarenal neck length and angulation for the fixation of the proximal graft component. Endograft fixation can be either suprarenal or infrarenal and much debate exists as to which approach is associated with optimum renal outcomes. This study aims to review the current literature with respect to the renal outcomes associated with conventional EVAR using suprarenal fixation (SRF) vs. infrarenal fixation (IRF).MethodsA search was conducted from major search indices (PubMed, Google Scholar and EMBASE) to identify relevant literature pertaining to renal outcomes in EVAR. Recent papers comparing SRF and IRF were evaluated and their findings discussed.Key Content and FindingsThe mechanism of renal function decline (RFD) following EVAR is uncertain and likely multifactorial. Aortic morphology, endograft type and surgical technique may all contribute to RFD. There is a significant degree of heterogeneity within the literature regarding study design and definitions of RFD. Recent literature suggests that RFD is more acute for SRF than IRF in the first post-operative year, but the clinical significance of this decline in patients with normal kidney function is questionable. Studies indicate that SRF is associated with accelerated RFD at 5 years, and that the RFD is worse in patients who are female and who have pre-existing renal insufficiency.ConclusionsSRF is associated with a greater decline in renal function than IRF in both short- and long-terms. Although clinically insignificant in the short-term, the limited available long-term evidence suggests that SRF results in a relatively accelerated decline in renal function when compared to IRF, but it is possibly partially explained by the higher prevalence of advanced degenerative/atherosclerotic disease in SRF cohorts. These trends are noted particularly in female patients and in patients with baseline renal insufficiency.

Long-term outcomes of endovascular aneurysm repair according to instructions for use adherence status

Long-term outcomes of endovascular aneurysm repair according to instructions for use adherence status

Late Neck Related Adverse Events are Rare Among Patients with Wide Aortic Neck Undergoing Endovascular Aneurysm Repair with the Ovation Endograft

Patients with wide aortic necks undergoing Endovascular Aneurysm Repair (EVAR) have been shown to be at a higher risk for neck-related complications. We aim to examine outcomes of EVAR with an endograft exerting minimal outward pressure (Ovation-Endologix) in patients with a large baseline neck diameter. We performed a retrospective single center study, including consecutive patients undergoing EVAR with the Ovation system from May 2011 to April 2021. Patients were divided in Groups 1 and 2 if the 20, 23, 26, 29 mm or the 34mm proximal diameter main body was used, respectively. According to the instructions for use of the device, for neck diameters 27-30mm the 34mm main body is required. Primary endpoint was rate of neckrelated complications during follow-up, (type Ia endoleak, migration >10mm and neck-related re-interventions) and rate of aortic neck dilatation (AND). AND was determined based on multiple aortic neck diameters that were recorded and compared between the 1-month computed tomography angiography (CTA) after EVAR and the last available follow-up CTA.Secondary endpoints were peri-procedural and follow-up outcomes such as endoleaks, reinterventions and overall mortality. In total 281 patients were included, 222 in Group 1 and 59 in Group 2. Patients in Group 2 presented significantly shorter neck length, higher neck angulation and more common reversed tapered configuration. Median follow-up was 36months (Range: 6-106). Early and late type Ia endoleak was observed in 4 and 2 patients in each group, respectively (P=0.063 and P=0.195, respectively). Distal migration was observed in 2 patients in Group 2 and AND was recorded in 2 patients in each group (P=0.195). Freedom from the primary endpoint was estimated at 98%, 94%, 94% at 12-, 36-, 60-months for Group 1 and at 98%, 95%, 86% for Group 2 (P-Value 0.266). Probability of survival was 95%, 86%, 75% at 12-, 36-, 60-months for Group 1 and 83%, 77%, 72% for Group 2 (P-Value 0.226).Multivariate regression analysis identified neither Group 1 versus Group 2 nor absolute value of aortic neck diameter as significant predictors of neck-related adverse events. Neck diameters did not display significant differences over time in any of the levels evaluated. EVAR with the Ovation endograft results in low rates of late neck related complications which is also true for patients with wide baseline aortic necks.