Outcomes Of Endovascular Aneurysm Repair Research Articles

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

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

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

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

Outcomes of Endovascular Abdominal Aortic Aneurysm Repair in Octogenarians: Meta-analysis and Systemic Review

This meta-analysis and systematic review aimed to highlight the results of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) to assess safety and effectiveness in patients older than 80 years of age compared with younger patients. PRISMA guidelines were used; quality was appraised, and data were extracted and analysed following the Cochrane collaboration. The MEDLINE and Embase databases were searched on December 31, 2016. All studies related to clinical outcomes following EVAR for AAA treatment in octogenarians compared with those in younger patients were included for a meta-analysis and systematic review of short- and midterm outcomes. Data were analysed using a fixed or random effects model by pooling and calculating odds ratios (ORs) or hazard ratios (HRs) and weighted mean differences, to investigate the safety and feasibility of endoluminal treatment in octogenarians. Published literature search identified nine observational studies, comprising 25,723 patients with AAA (5989 octogenarians and 19,734 younger patients). More males (OR 0.621, p = .002) and smokers (OR 0.457, p < .001) were observed in the younger group. Frequent concomitant diseases were associated with advanced age, thus, the procedural duration, blood loss estimation, and length of stay were considerably higher among octogenarians. Although elderly patients have a higher 30 day mortality (2.7% vs 1.5%, p < .001), endoleak, pulmonary, and renal diseases, no significant difference was found in the technical success of the procedure. As expected, the HR for octogenarians was markedly higher than that of younger patients (HR 1.946, p < .001) for midterm all-cause mortality. However, the re-intervention rate to maximum follow-up period of 5 years was not significantly different (HR 1.148, p = .408) between the groups. Compared with younger patients, EVAR in octogenarians is associated with a significantly higher but still acceptable peri-operative and midterm mortality rate. Because of similar midterm re-intervention rates, these findings suggest that EVAR remains an appropriate therapeutic approach in the elderly group if comprehensive pre-operative evaluation and post-operative surveillance are incorporated.

Clinical Outcomes After Endovascular Repair and Open Surgery to Treat Immunoglobulin G4–Related and Nonrelated Inflammatory Abdominal Aortic Aneurysms

Purpose: To compare the follow-up results of endovascular aneurysm repair (EVAR) vs open surgery (OS) for inflammatory abdominal aortic aneurysms (IAAAs) with regard to immunoglobulin G4–related diseases (IgG4-RD), which are fibrous inflammatory conditions characterized by elevated serum IgG4 concentrations and numerous infiltrations of IgG4+ plasmacytes. Methods: Between January 2005 and December 2015, 91 patients were treated with EVAR (begun in 2008) and 166 patients underwent OS for AAA. Forty of these 257 patients had IAAAs identified by a >2-mm thickness of periaortic fibrosis (PAF). Of these 40, 21 had pathologically confirmed IgG4-RD and/or serum IgG4 concentrations ≥135 mg/dL (classified IgG4+); 8 (mean age 76 years; 8 men) were treated with EVAR and 13 (mean age 71 years; 11 men) underwent OS. Of the 19 IgG4– patients with IAAA, 9 (mean age 71 years; 8 men) had EVAR and 10 (mean age 75 years; 9 men) had OS. The 4 subgroups were compared in terms of symptoms, complications, inflammation markers, PAF, and aneurysm diameter using the latest midterm follow-up data (12–24 months). Results: Preoperative aneurysm diameter, PAF, gender, median age, symptoms, and median follow-up period were similar in all groups. Preoperative serum IgG4 was equal in EVAR and OS IgG4+ groups. Compared with the OS IgG4+ group, EVAR IgG4+ patients more frequently had postoperative IgG4 increase (5/8; p=0.006) and PAF progression (5/8; p=0.027), higher postoperative serum IgG4 levels (median 141 mg/dL; p=0.034), a thicker postoperative PAF (median 5.1 mm; p=0.016), and persistent clinical symptoms (p=0.006). Compared with EVAR IgG4– patients, the EVAR IgG4+ patients showed significantly thicker postoperative PAF (p=0.024) and larger increases in postoperative sac diameter (median +13.1 mm; p=0.030). Postoperative PAF and sac diameter frequently and synchronously became worse in the EVAR IgG4+ subgroup with increased IgG4 during follow-up. The rate of change in IgG4 significantly positively correlated with the rates of change in PAF (R=0.555, p=0.03) and sac diameter (R=0.902, p=0.003). Conclusion: Though sample sizes were rather small, this pilot study suggested that EVAR-treated IgG4+ IAAA patients have a higher risk of persistent symptoms and increases in PAF, sac diameter, and IgG4 levels. Therefore, OS should be preferred for complete recovery. Frequent monitoring of the postoperative serum IgG4 is necessary following EVAR in IgG4+ patients to detect these complications.

Conical neck is strongly associated with proximal failure in standard endovascular aneurysm repair

ObjectiveHostile proximal aortic neck (HN) challenges the suitability for standard endovascular aneurysm repair (EVAR) of patients at high risk for “open” repair. However, there has been little if any focus placed on the individual role of the “nonlength” HN features in EVAR outcomes. The aim of this study was to evaluate their individual and potentially predictive role in outcomes of EVAR under HN conditions. MethodsData of 156 consecutive EVAR patients with short (<15 mm) HN, treated with the Endurant device (Medtronic Cardiovascular, Santa Rosa, Calif) at three European academic vascular centers between 2007 and 2015, were collected and retrospectively analyzed. All patients had at least one of the four well-known nonlength HN criteria (width >32 mm or bulge, angulation >60 degrees, reverse taper anatomy, and circumferential thrombus or calcification >50%) and underwent standard EVAR without additional techniques, such as use of chimney grafts or endoanchors. Primary end points were absence of type IA endoleak at 1 month and midterm follow-up and aneurysm sac stabilization or shrinkage. Secondary end points were 30-day mortality, overall survival, and secondary interventions related to EVAR. The study cohort was classified in two subgroups related to neck length (length <10 mm and length between 10 and 14 mm) as well as in two subgroups according to on-label or off-label stent graft use. ResultsMean clinical and radiologic follow-up was 41.1 ± 24.7 and 31.7 ± 19.0 months, respectively. Overall EVAR-related mortality was 1.9% (n = 3). The total type IA endoleak rate was 5.8% (n = 9). In four patients, the type IA endoleak was detected intraoperatively and solved by endovascular means. A type IA endoleak was detected in three patients at 1 month and in two patients at 2-year follow-up. During follow-up, five patients showed an increase of aneurysm diameter due to type II endoleak and were treated by secondary endovascular reinterventions. The total number of all EVAR-related secondary procedures in the midterm was 12 (7.7%). Univariate analysis showed that the center of treatment and the clinical or anatomic features were not associated with adverse outcomes. Multiple regression and Cox regression analysis of HN features revealed that reverse taper anatomy (conical neck) was the single and significantly associated predictor of proximal EVAR failure (P < .012). Width >32 mm, angulation >60 degrees, and calcification or thrombus were not associated with adverse outcomes. Analysis between HN length cohorts and between on-label and off-label subgroups revealed no difference in outcomes. ConclusionsA conical neck in hostile anatomies represents the single strongest factor associated with proximal failure of standard EVAR. This finding should be considered and highlighted apart from the length of the infrarenal neck to prevent midterm failure of standard EVAR.

Commentary to “Assessment of Competence in EVAR Procedures – A Novel Rating Scale Developed by the Delphi Technique”

In the past two decades the preferred treatment of abdominal aortic aneurysms has changed from open to endovascular aneurysm repair (EVAR). In European countries a steady increase in the use of EVAR has been observed with improved outcomes. To evaluate endovascular skills and to standardize the training and performance of trainees, the authors have developed a rating scale to assess these competences in EVAR.3 A panel of 32 international experts have reduced a pool of 83 items to seven pivotal assessment items. The authors proposed a five point Likert scale for each of these items to the final appraisal tool: EVARATE. The research team did a great job to develop this standardised assessment tool, but omitted several items not directly related to the endovascular aortic intervention although essential for proper EVAR outcomes. Moreover, the expert panel voted out several items, which were considered intrinsic to other endovascular skills. A clear distinction was made between fundamental endovascular skills, identified in a recent Delphi consensus study, and advanced procedure specific skills.4 The fundamental endovascular skills were considered requisite before being allowed to perform EVAR. Consequently, EVARATE is a procedure specific evaluation tool limited to deployment of a modular infrarenal aortic stent graft. Key elements of stent graft placement and deployment can be assessed, but other important aspects of EVAR, like planning and sizing, taking care of the access arteries (puncture skills and use of closure devices) and radiation protection are not addressed. Also, more advanced skills like troubleshooting (to overcome stenosed access arteries and endovascular adjuncts in case of acute type IA endoleaks) and performing chimney and fenestrated EVARs cannot be evaluated. In the footsteps of EVARATE, additional assessment tools for all procedural steps must be developed to cover a complete trainee appraisal of real world EVAR competence including more hostile aortic and iliac anatomy. Although the selection of the assessment items has been done thoroughly, the evaluation method using a Likert scale has yet to be validated. A Likert scale may be arbitrary, using subjective descriptors of quality like “unacceptable”, “acceptable”, and ‘superior’. Also, the assessment of the level of trainee independence performing the several procedural steps is lacking. The latter is essential to allow trainees to perform EVAR procedures with less supervision during their training. In conclusion, EVARATE contains well selected assessment items that can be used for structured feedback and measuring the progress of EVAR training. After validation of this assessment tool for the deployment of aortic stent grafts, EVARATE may be used as a necessary blueprint for developing additional evaluation tools for all aspects of EVAR.

Third- versus Second-Generation Stent Graft for Endovascular Aneurysm Repair: A Device-Specific Analysis

Our purpose is to analyze the outcomes of endovascular aneurysm repair (EVAR) in patients treated with Excluder endograft (W.L. Gore and Associate, Flagstaff, AZ), comparing second generation, featuring SIM-PULL delivery system (ExSP) and third generation, featuring C3 (ExC3), concerning intraprocedural data and long-term outcomes. In our single-center, comparative study, we retrospectively analyzed all patients undergoing elective EVAR with Excluder from May 2008 to December 2015. This cohort was firstly divided according to the design of the endograft used, and then, two subgroups of complex procedures were identified according to International Standards. Preliminary end points were early- and mid-term outcomes. Primary end point was procedural data (i.e., procedural and fluoroscopy time, radiation dose (DAP), and contrast medium amount). The study included 64 patients (24 ExSP and 40 ExC3) with a mean follow-up of 31.6±22.9months. Patients in ExC3 group had significantly more risk factors (past or present history of smoking, P=0.019), comorbidities (chronic heart failure and chronic kidney disease, both P=0.032), as well as a more unfavorable anatomy (neck angulation, P=0.035). Concerning preliminary outcome, no significant between-group difference was noted. As for intraoperative data, procedure duration was significantly shorter: 120 vs. 151 min (P=0.002) in the overall population and 129 vs. 173 min (P=0.004) in complex cases. A significant reduction was also found in fluoroscopy time and radiation exposure: 24,084 vs. 32,548 cGy/cm2 (P=0.020) in the overall population and 26,770 vs. 41,104 cGy/cm2 (P=0.003) in complex cases. No significant difference was found for contrast volume. The study shows that new C3 excluder enables to reduce radiation exposure and procedural time compared to the previous device. C3 excluder results are comparable to those of the previous device in spite of more comorbidities and complex anatomy of the treated patients. Further studies are needed to assess device performance on longer-term follow-up.

Outcomes of endovascular aneurysm repair performed in abdominal aortic aneurysms with large infrarenal necks

ObjectiveThe aim of this study was to evaluate midterm clinical and morphologic outcomes after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) with large (≥28 mm) infrarenal neck. MethodsFrom 2009 to 2012, we prospectively collected and retrospectively analyzed clinical, morphologic, and intraoperative and postoperative data of patients undergoing EVAR for wide-neck AAA at three European vascular surgery units. All patients had computed tomography angiography follow-up of ≥24 months. The early end points were technical success and proximal type I endoleak at 30 days. The midterm end points were type Ia endoleak, freedom from reintervention (FFR), survival, AAA-related mortality, and infrarenal and suprarenal aortic diameter progression. The aortic diameters were measured on three-dimensional workstation center lumen line reconstructions, 1 cm below the lowest renal artery, at the level of the renal arteries, at the superior mesenteric artery, and at the celiac trunk. Preoperative and 24-month aortic diameters were compared by paired t-test. Survival and FFR were evaluated by Kaplan-Meier analysis. ResultsDuring the study period, 118 patients (74 ± 8 years) were enrolled. The mean aneurysm diameter was 61 ± 10 mm. Suprarenal and infrarenal fixation endografts were implanted in 102 (86%) and 16 (14%) patients, respectively. The mean main body oversizing was 17% ± 9%. Technical success rate was 98% (three type Ia endoleaks at 30 days). The mean follow-up was 38 ± 12 months. Fourteen type Ia endoleaks (12%) were detected during follow-up. Survival at 3 years and 5 years was 89% and 70%, respectively. Four deaths (3.4%) were type Ia endoleak related. FFR at 1 year, 3 years, and 5 years was 96%, 83%, and 82%, respectively. Eight reinterventions (7%) were proximal neck related. All infrarenal and suprarenal aortic diameters increased at 24 months. The mean increase was 11% for the lowest renal artery (29.1 ± 1.1 mm preoperatively vs 32.3 ± 4.5 mm at 24 months; P < .001), 3% to 5% at the level of the renal arteries, and <3% for the superior mesenteric artery and the celiac trunk. Neck length <15 mm (P = .032), stainless steel endograft (P = .003), and type Ia endoleak at 24 months (P = .001) were associated with infrarenal neck enlargement on multivariate logistic regression. ConclusionsEVAR performed in AAAs with large necks is associated with a significant infrarenal aortic neck enlargement at 24 months as well as with a high risk of proximal type I endoleak and proximal neck-related reinterventions. In this subgroup of patients, main body oversizing >15% and suprarenal sealing should be considered.

Comparison of midterm results for the Talent and Endurant stent graft

ObjectiveStent graft evolution is often addressed as a cause for improved outcomes of endovascular aneurysm repair for patients with an abdominal aortic aneurysm. In this study, we directly compared the midterm result of Endurant stent graft with its predecessor, the Talent stent graft (both Medtronic, Santa Rosa, Calif). MethodsPatient treated from January 2005 to December 2010 in a single tertiary center in The Netherlands with a Talent or Endurant stent graft were eligible for inclusion. Ruptured abdominal aortic aneurysms or patients with previous aortic surgery were excluded. The primary end point was the Kaplan-Meier estimated freedom from secondary interventions. Secondary end points were perioperative outcomes and indications for secondary interventions. ResultsIn total, 221 patients were included (131 Endurant and 90 Talent). At baseline, the median aortic bifurcation was narrower for the Endurant (30 mm vs 39 mm; P < .001). Median follow-up was 64.1 ± 37.9 months and 59.2 ± 25.3 months for Talent and Endurant, respectively. The estimated freedom from secondary interventions at 30 days, 1 year, 5 years, and 7 years was 94.3%, 89.4%, 72.2%, and 64.1% for Talent and 96.8%, 89.3%, 75.2%, and 69.2% for Endurant (P = .528). The indication for secondary interventions does differ; more patients required an intervention for a proximal neck-related complication (type Ia endoleak or migration) in the Talent group (18.2% vs 4.8%; P = .001), whereas more interventions for iliac limb stenosis were seen in the Endurant group (0.0% vs 4.8%; P = .044). In a binomial regression analysis, suprarenal angulation, infrarenal neck length, and type of stent graft were independent predictors of neck-related complications. ConclusionsEvolution from the Talent stent graft into the Endurant has resulted in significant reduction of infrarenal neck-related complications; on the other hand, iliac interventions increased. The overall midterm secondary intervention rate was comparable.

Sellado distal en ilíaca externa: ramificación ilíaca frente a la exclusión de la arteria hipogástrica

ObjectiveTo compare the results of endovascular aneurysm repair (EVAR) in external iliac (EI) as distal sealing using an iliac branch device (IBD) versus the exclusion of the internal iliac artery. PatientsThe study included 67 patients treated by EVAR between 2007 and 2014 that were divided into two groups. Group I included 25 iliac arteries receiving an iliac branch device, and group ii with 77 iliac arteries in which their sealing was in EI with hypogastric exclusion. MethodsA retrospective study was conducted in an assessment and comparison was made using the characteristics, risk factors, intra-operative parameters, and days in hospital. Complications, such as ipsilateral buttock claudication, limb occlusion, device migration, re-interventions, and growth of common iliac (CI), were followed by physical and radiological examinations. ResultsMean follow-up was 26.7, and 49.3 months in the group i and ii, respectively. There were no differences in days in hospital, but the fluoroscopy time, radiation dose, procedure time, and contrast was higher in group i.The hypogastric artery was embolised in 50.6% of group ii, with 92% technical success with the IBD in group i.The complication rate between group i and ii: buttock claudication was 4% and 36% (P<.0001), the limb occlusion rate at 24 months was 6% and 10.4% (P<.2), and re-intervention was 6% and 12% (P=.1), respectively. Group II had 4 cases of distal migration, and 4 cases requiring extension to EI. The CI diameter decreased by 3.4cm and 2cm, respectively (P=.09). ConclusionIn our series, the low rate of complications in distal sealing with iliac branch devices could justify their use in selected patients.

Implications of concomitant hypogastric artery embolization with endovascular repair of infrarenal abdominal aortic aneurysms

ObjectiveHypogastric artery embolization (HAE) is associated with significant risk of ischemic complications. We assessed the impact of HAE on 30-day outcomes of endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms. MethodsWe queried the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2014 to identify and to compare clinical features, operative details, and 30-day outcomes of EVAR with those of concomitant HAE with EVAR (HAE + EVAR). Multivariate analysis was performed to determine preoperative and intraoperative factors associated with development of significant complications observed in patients with HAE + EVAR. ResultsIn a cohort of 5881 patients, 387 (6.6%) underwent HAE + EVAR. Compared with EVAR, a higher incidence of ischemic colitis (2.6% vs 0.9%; P = .002), renal failure requiring dialysis (2.8% vs 1%; P = .001), pneumonia (2.6% vs 1.3%; P = .039), and perioperative blood transfusion (17% vs 13%; P = .024) was noted after HAE + EVAR. Thirty-day thromboembolic events, strokes, myocardial infarction, lower extremity ischemia, reoperation, and readmission rates were not significantly different (P > .05). Mortality at 30 days in HAE + EVAR patients was 4.1% compared with 2.5% with EVAR (P = .044). HAE was independently associated with increased risk of colonic ischemia (adjusted odds ratio, 2.98; 95% confidence interval, 1.44-6.14; P = .003) and renal failure requiring dialysis (adjusted odds ratio, 2.22; 95% confidence interval, 1.09-4.53; P = .029). However, HAE was not an independent predictor of mortality. Average length of hospital stay was 4 ± 8.5 days after HAE + EVAR vs 3.3 ± 5.9 days after EVAR (P = .001). ConclusionsConcomitant HAE with EVAR is associated with longer and more complicated hospital stays. Ischemic colitis is a rare complication of EVAR. HAE increases the risk of ischemic colitis and renal failure requiring dialysis. This study highlights the importance of hypogastric artery preservation during EVAR.

Carbon Dioxide as Contrast Medium to Guide Endovascular Aortic Aneurysm Repair

Iodine contrast medium (ICM) is considered to be gold standard in endovascular procedures, but its nephrotoxicity and hypersensitivity limit the widespread use. Carbon dioxide (CO2) is considered as an alternative for endovascular procedures in patients with contraindication to ICM. However, no studies have compared the outcomes of endovascular aneurysm repair (EVAR) performed with ICM or CO2 among patients with no contraindication to ICM. From May 2012 to April 2014, 36 patients with abdominal aortic aneurysms underwent EVAR in a prospective, randomized, and controlled study. Patients were randomized into 2 groups, CO2 or ICM group. We were able to perform the proposed procedures in all patients in this study. There were no conversions to open surgery and no CO2-related complications. Endovascular material costs, duration of surgery, and time of fluoroscopy were similar between groups, and the cost of the contrast media was smaller in the CO2 group than in the ICM group. Among CO2 group procedures, 62.5% of the patients needed ICM complementary use. The use of CO2 as a contrast medium for EVAR is an alternative in patients with no restriction for ICM, with similar outcomes when compared to ICM, regarding duration of surgery, duration of fluoroscopy, and endovascular material costs. Using CO2, there were no changes in creatinine clearance and no risk of hypersensitivity reactions; moreover, there was a reduction in contrast-related costs for EVAR procedures. However, in our study, additional use of ICM to visualize the internal iliac artery was needed in most procedures.

PC030. Clinical Outcomes of Open and Endovascular Abdominal Aortic Aneurysm Repair Over a 15-Year Period in the Veteran Population

Disease acuity and perioperative morbidity amongst Veterans is considered to be greater than in the general U.S. population. The reduced morbidity and mortality associated with endovascular aneurysm repair (EVAR) hold promise of improving safety of management of abdominal aortic aneurysms (AAA) in this population. We examine the outcomes of open repair and EVAR, over a 15-year period, in a Veteran population at our regional VA Medical Center. With IRB approval, a retrospective review was conducted of all patients who underwent open infrarenal open AAA repair and EVAR at a single VA hospital between 2000 and 2015. Emergency AAA repairs were excluded. Open and EVAR groups were compared. Variables reviewed include demographics, medical history, surgical details, complications (perioperative and late), and mortality. The primary end points were 30-day, 6-month, 1-year, and 2-year mortality. Survival was estimated using actuarial life-table method. During the 15-year study period, 212 patients (mean age, 71.44 years) underwent 91 open (70.37 years) and 121 endovascular (72.56 years) AAA repairs (Table). Perioperative (30-day) complications, including pneumonia, creatinine elevation, and surgical site infection, were significantly increased in the open group. Need for dialysis, graft infection, pulmonary embolism, cardiac enzyme elevation were not different between groups. Mortality was greater in the open group (3) than the EVAR group (0), but this was not statistically significant. Late morbidity was not significantly different between groups ,with exception of endoleaks and aortic enlargement after EVAR. The EVAR group had 27 (22.73%) endoleaks (7 type I and 24 type II), 20 (18.2%), and 15 (12.3%) required interventions. Our study is consistent with the national trend toward EVAR as the preferred approach for AAA repair. Overall perioperative mortality for AAA repairs (0% EVAR, 2% open) was below the national average. Mortality at 2 years was similar for the open and EVAR groups. Our study supports EVAR as a safe elective operation with low mortality and few complications in a group of patients who are characterized by greater disease acuity and elevated complication rates. With lower perioperative mortality and shorter recovery time, EVAR has become the preferred method of AAA management in the Veteran population.TableOpen repair and endovascular aneurysm repair (EVAR) in 212 patientsPerioperative complications (30-day mortality)Open repairEVARP valuen = 91 (42.9%), No. (%)n = 121 (57%), No. (%)Creatinine elevation6 (6.6)0 (0.0).003Dialysis2 (2.2)1 (0.8).38Creatine kinase elevation3 (3.2)0 (0.0).39Surgical site infection6 (6.6)2 (1.6).036Graft infection1 (1.1)1 (0.8).812Pneumonia10 (10.9)0 (0.0).001Late morbidity (>30 days) Claudication4 (4.4)10 (8.3).305 Incisional hernia5 (5.4)1 (8.2).016 Graft infection0 (0.0)0 (0.0) Erectile dysfunction4 (4.4)5 (4.1).807 AAA enlargement2 (2.1)20 (16.5).002 Migration0 (0.0)1 (0.8).008 Rupture0 (0.0)0 (0.0)Mortality 30 days2 (2.2)0 (0.0).099 6 months5 (5.4)2 (16.5).116 1 year8 (8.7)4 (3.3).081 2 years11 (12.1)6 (4.9).030 5 years24 (26.1)17 (14.0).013 10 years38 (41.8)19 (15.8)<.001Endoleak (>30 days)27 (22.73) Type I7 Type II24AAA, Abdominal aortic aneurysm. Open table in a new tab

Results of standard suprarenal fixation endografts for abdominal aortic aneurysms with neck length ≤10 mm in high-risk patients unfit for open repair and fenestrated endograft

The aim of this study was to evaluate long-term outcomes of endovascular aneurysm repair (EVAR) using a standard suprarenal fixation endograft in abdominal aortic aneurysms (AAAs) with infrarenal neck length ≤10mm (short-neck AAA [SN-AAA]). From 2005 to 2010, data of high-risk patients with SN-AAA, unfit for open repair (OR) and fenestrated EVAR, were prospectively collected. Follow-up was performed by duplex ultrasound and contrast-enhanced ultrasound or computed tomography angiography at 1month, 6months, and 12months and yearly thereafter. The primary end point was AAA-related mortality. Secondary end points were proximal type I endoleak, freedom from reintervention, and AAA shrinkage (>5mm). Sixty patients (mean age, 74.9± 6.2years; American Society of Anesthesiologists class 3 [85%] and class 4 [15%]) were enrolled. The mean aneurysm diameter and neck length and diameter were 60.4± 12.2mm, 8.4± 1.6mm, and 23.5± 3mm, respectively. Four (7%) patients were symptomatic and 15 (25%) had rapid AAA enlargement (>5mm/6months). Cook Zenith Flex (Cook Medical, Bloomington, Ind) endografts (32) and Medtronic Endurant (Medtronic, Santa Rosa, Calif) endografts (28) were implanted. The mean follow-up was 51± 18months. Survival at 5years was 70%. There were three (5%) type I endoleaks. One was sealed by endovascular reintervention, and two (3%) underwent conversion to OR for AAA rupture at 8 and 36months. Both patients died (2/60; 3% AAA-related mortality). Reinterventions were necessary for another five (8%) patients, and they were not proximal neck related. Freedom from reintervention at 5years was 90%. In 49 (82%) cases, there was AAA shrinkage; the AAA diameter remained stable in nine (15%) and increased in two (3%) cases. Severe proximal angle (α neck angle ≥60 degrees) was associated with type Iendoleak (P= .010) and reinterventions (P= .010). The neck length<7mm(P= .030) was associated with reinterventions (P= .017). Suprarenal fixation EVAR in SN-AAA with a straight, not wide neck and 7- to 10-mm aortic neck length can be considered safe and effective in patients who are unfit for OR and fenestrated EVAR. For these cases, long-term data showed acceptable results in preventing aneurysm rupture and related mortality.

Endovascular Treatment of Internal Iliac Artery Aneurysms: Single Center Experience.

ObjectiveInternal iliac artery aneurysms (IIAA) are rare, representing only 0.3% of aortoiliac aneurysms. Its treatment with open surgery is complex and associated with high morbidity and mortality, which led to increasing application of endovascular solutions. In this study, we aimed to evaluate outcomes of endovascular aneurysm repair (EVAR) of IIAA in one institution.MethodsWe retrospectively reviewed all cases of IIAA treated with endovascular techniques between 2003 and 2014. Endpoints were morbidity, mortality, freedom from pelvic ischemic symptoms (buttock claudication, ischemic colitis, and spinal cord injury), and need for reintervention.ResultsThere were 16 patients, 13 males and 3 females, with mean age of 75.1±7 years. A total of 20 IIAA (4 cases were bilateral), with mean diameter of 37.9 mm, were treated. EVAR was performed in 13 (81.3%) patients, with associated internal iliac artery's outflow occlusion in 2. Iliac branch device was used in one patient. Two patients underwent endovascular IIAA embolization alone. One patient underwent percutaneous, transgluteal, IIAA embolization. IIAA flow preservation in at least one internal iliac artery was possible in 9 (56.3%) patients. Early mortality was 7% (1 case). Early morbidity was 18.8%. Pelvic ischemic complications occurred in 1 (7%) patient with buttock claudication. Late reintervention was needed in 3 patients, none of them for IIAA related complications.ConclusionEndovascular treatment of IIAA is technically feasible and durable. Although overall morbidity is relatively high, major complications are infrequent and perioperative mortality is low. internal iliac artery flow preservation is technically challenging and, in a significant number of cases, not possible at all.

The Outcomes of Endovascular Aneurysm Repair with the Chimney Technique for Juxtarenal Aortic Aneurysms.

We collected our experience in the use of chimney technique with endovascular aneurysm repair (Ch-EVAR) for juxtarenal aortic aneurysms (JAAs), and reviewed the outcomes. The patients who were treated with Ch-EVAR between January 2012 and December 2015 were retrospectively reviewed. All of the patients underwent endovascular aneurysm repair (EVAR) under general anesthesia. Femoral arterial access was obtained to place the main body of the endograft; brachial or axillary access was obtained to perform the placement of the chimney stent. We treated 12 patients with 15 renal arteries using the Ch-EVAR procedure. Technical success was achieved in 11 of the 12 (91.6%) cases. Within the first 30 days of postoperative period, the target vessel patency rate was 93.3% (14 of 15 renal arteries). After a median follow-up period of 28 months, one patient required Ch-EVAR-related re-intervention due to a type Ia endoleak, and 13 of the 15 renal arteries were patent at the end of the follow-up period. Our findings demonstrate that Ch-EVAR can be completed with a high rate of success. Although early target vessel occlusion or early postoperative mortality might occur, Ch-EVAR could be an alternative treatment for JAA, especially in high risk patients.

Endovascular Treatment of Inflammatory Infrarenal Aortic Aneurysms.

The aim of this study was to evaluate short- and midterm outcomes of endovascular aneurysm repair in patients with inflammatory abdominal aortic aneurysm (IAAA) focusing on changes in perianeurysmal inflammation and hydronephrosis. A retrospective study was performed considering data prospectively gathered from 1998 to 2013 in 3 centers. Patient demographics, preoperative clinical characteristics, clinical presentation, preoperative imaging measurements, procedural, and postoperative data were collected. Main outcome was to define evolution of periaortic fibrosis and hydronephrosis at computed tomography angiography (CTA) during follow-up. A total of 22 patients (male n = 20; mean age 70.9 years ± 9.3) were included (mean AAA diameter: 58 mm ± 11, symptomatic: 50%, ruptured: 9.1%). Hydroureteronephrosis was preoperatively diagnosed by CTA in 6 (27.3%) cases. Median clinical follow-up was 2.2 years (range 0.1-14.5). Nine patients died during follow-up. At 1, 2, 4, and 6 years, overall survival was 85.4%, 74.3%, 56.6%, and 49.5%, respectively. Among these 13 patients with CTA follow-up, the mean AAA diameter was 56.2 mm ± 15.5, and progression of sac diameter was detected in 1 (7.7%) patient. Median maximum thickness of perianeurysmal inflammation was 5 mm (range 2-11) and decreased/remained unchanged in 92.3% of patients. Regression of hydroureteronephrosis occurred in 3 of 5 patients available for follow-up. There were no cases of de novo hydroureteronephrosis. Endovascular treatment of IAAA has comparable short-term outcomes with non-IAAA. During midterm follow-up, aneurysm sac progression is rare, and perianeurysmal fibrosis decreases or remains unchanged in most cases. Hydronephrosis regression can occur in some but not all instances and thus warrants close surveillance.

Gender Differences in Aortic Neck Morphology in Patients with Abdominal Aortic Aneurysms Undergoing Elective Endovascular Aneurysm Repair

Previous studies have demonstrated that women tend to have adverse aortic neck morphology leading to exclusion of some women from undergoing endovascular aneurysm repair (EVAR). The objective of this study is to investigate differences in aortic neck morphology in men versus women, changes in the neck morphology and sac behavior after EVAR, and investigate how these features may influence outcomes. We conducted a retrospective review of elective EVARs (2004-2013). We excluded patients who underwent elective EVAR with no postoperative imaging available and those patients with fenestrated repairs. Using TeraRecon and volumetric analysis, several features were investigated. These included percent thrombus, shape, length, angulation of the neck, and changes in neck and abdominal aortic aneurysm diameter. A total of 146 patients were found to meet inclusion criteria (115 men and 31 women) with similar baseline characteristics. Neck angulation was greater in women (23.9° vs. 13.5°; P < 0.028). The percent thrombus in women was higher than men (35.4% vs. 31%; P < 0.02). Abdominal aneurysm's were smaller in women at 1 year (4.2 cm vs. 5.1 cm; P < 0.002), and secondary interventions were higher in men (11.3% vs. 0%; P < 0.05). Other features such as neck shape, changes in neck diameter, neck length, and percent oversizing of graft where not statistically different between genders. Gender differences in neck characteristics and changes in neck morphology do not appear to adversely affect EVAR outcomes. Longer follow-up is necessary to further assess whether these findings are clinically durable.

Outcomes of endovascular aneurysm repair with contemporary volume-dependent sac embolization in patients at risk for type II endoleak

The aim of this study was to evaluate outcomes of intraoperative aneurysm sac embolization during endovascular aneurysm repair (EVAR) in patients considered at risk for type II endoleak (EII), using a sac volume-dependent dose of fibrin glue and coils. Between January 2012 and December 2014, 126 patients underwent EVAR. Based on preoperative computed tomography evaluation of anatomic criteria, 107 patients (85%) were defined as at risk for EII and assigned to randomization for standard EVAR (group A; n = 55, 44%) or EVAR with intraoperative sac embolization (group B; n = 52, 42%); the remaining 19 patients (15%) were defined as at low risk for EII and excluded from the randomization (group C). Computed tomography scans were evaluated with OsiriX Pro 4.0 software to obtain aneurysm sac volume. Freedom from EII, freedom from EII-related reintervention, and aneurysm sac volume shrinkage at 6, 12, and 24 months were compared by Kaplan-Meier estimates. Patients in group C underwent the same follow-up protocol as groups A and B. Patient characteristics, Society for Vascular Surgery comorbidity scores (0.99 ± 0.50 vs 0.95 ± 0.55; P = .70), and operative time (149 ± 50 minutes vs 157 ± 39 minutes; P = .63) were similar for groups A and B. Freedom from EII was significantly lower for group A compared with group B at 3 months (58% vs 80%; P = .002), 6 months (68% vs 85%; P = .04), and 12 months (70% vs 87%; P = .04) but not statistically significant at 24 months (85% vs 87%; P = .57). Freedom from EII-related reintervention at 24 months was significantly lower for group A compared with group B (82% vs 96%; P = .04). Patients in group B showed a significantly overall mean difference in aneurysm sac volume shrinkage compared with group A at 6 months (-11 ± 17 cm(3) vs -2 ± 14 cm(3); P < .01), 12 months (-18 ± 26 cm(3) vs -3 ± 32 cm(3); P = .02), and 24 months (-27 ± 25 cm(3) vs -5 ± 26 cm(3); P < .01). Patients in group C had the lowest EII rate compared with groups A and B (6 months, 5%; 12 months, 6%; 24 months, 0%) and no EII-related reintervention. This randomized study confirms that sac embolization during EVAR, using a sac volume-dependent dose of fibrin glue and coils, is a valid method to significantly reduce EII and its complications during early and midterm follow-up in patients considered at risk. Although further confirmatory studies are needed, the faster aneurysm sac volume shrinkage over time in patients who underwent embolization compared with standard EVAR may be a positive aspect influencing the lower EII rate also during long-term follow-up.

Open surgery (OS) versus endovascular aneurysm repair (EVAR) for hemodynamically stable and unstable ruptured abdominal aortic aneurysm (rAAA).

Endovascular aneurysm repair (EVAR) is an alternative treatment for ruptured abdominal aortic aneurysms (rAAA) in hemodynamically (hd) stable patients. Treatment for patients with hd-unstable rAAA remains controversial. The aim of this study was to compare the outcomes of EVAR and open surgery (OS) in hd-stable and hd-unstable rAAA patients using meta-analysis. The first part of this study included 48 articles that reported the treatment outcomes of rAAA managed with EVAR (n=9610) and OS (n=93867). The second part, which is the focus of this study, included 5 out of 48 articles, which further reported treatment results in hd-stable (n=198) and hd-unstable (n=185) patients. When heterogeneity among the groups was observed, a random-effects model was used to calculate the adjusted odds ratios (OR) or in cases of non-heterogeneity, a fixed-effects model analysis was employed. In the first part of this study, the in-hospital mortality rate was found to be lower in the EVAR group than in the OS group (29.9 vs 40.8%; OR 0.59; 95% CI 0.52-0.66; P<0.01). In the second part of this study, 383 patients from 5 articles were included: 152 patients were treated by EVAR, and 231 were treated by OS. The total mortality was 147/383 (38.4%), while the mortality of the EVAR group and the OS group was 25.7% (39/152) and 46.8% (108/231), respectively. In the hd-stable group, the in-hospital mortality after EVAR was significantly lower than that after OS [18.9% (18/95) vs 28.2% (29/103); OR 0.47; 95% CI 0.22-0.97; P=0.04]. For the hd-unstable rAAA patients, the in-hospital mortality after EVAR was significantly lower than that after OS [36.8% (21/57) vs 61.7% (79/128); OR 0.40; 95% CI 0.20-0.79; P<0.01]. This study indicated that compared with OS, EVAR in hd-unstable rAAA patients is associated with improved outcomes. Available publications are currently limited; thus, the best treatment strategy for this subgroup of patients remains unclear. Further clinical studies are needed to provide more detailed data, such as the shock index and long-term results.