Risk Of Endoleak Research Articles

Long-term anticoagulation is associated with type II endoleaks and failure of sac regression after endovascular aneurysm repair

ObjectiveWithin the context of endovascular aneurysm repair (EVAR), the role of anticoagulation therapy on endoleak development and subsequent reintervention is unclear with conflicting data in the literature. The hypothesis of this study is that long-term anticoagulation is associated with persistent type II endoleaks and failure of sac regression in patients undergoing endoluminal repair of intact infrarenal aortic aneurysm. MethodsRetrospective cohort abstracted from the Vascular Quality Initiative index hospitalization and long-term follow-up datasets for EVAR (2003-2017) were included in the analysis. Patients not taking aspirin preoperatively and postoperatively were excluded. Patients taking anticoagulation and aspirin concomitantly (treatment) after the index procedure were compared against patients taking aspirin alone (control). Anticoagulation included warfarin and novel oral anticoagulants, including factor Xa inhibitors and direct thrombin inhibitors. One-to-one greedy matching using propensity scores was implemented to match patients. The primary end points were failure of aneurysm sac regression, sac expansion, risk of endoleak, and reintervention rate for endoleak at follow-up. Sac regression was defined as a decrease of at least 5 mm and sac expansion was defined as an increase of at least 5 mm. ResultsThere were 9004 patients who received ASA alone and 332 patients who received ASA and anticoagulation. Propensity scores were used to create 301 matching pairs to account for differences in baseline characteristics and comorbidities, including but not limited to age, sex, smoking, coronary artery disease, heart failure, and chronic kidney disease between the treatment and control groups. After adjusting for covariables anticoagulation use was independently associated with a significantly decreased abdominal aortic aneurysm sac regression (41.59% vs 58.41%; P = .001), but no statistically significant difference in sac expansion with long-term anticoagulation use (9.7% vs 4.9%; P = .056). There was increased risk of type II endoleaks (11.96% vs 6.31%; P = .023; relative risk, 1.89; 95% confidence interval, 1.11-3.23; P = .016), but no significant differences in type I, III, or indeterminate endoleaks. There was no statistical difference in 2-year reintervention rates (4.32% vs 2.66%; hazard ratio, 1.43; 95% confidence interval, 0.55-3.77; P = .461). There were no differences in any primary outcome between warfarin and novel oral anticoagulants. ConclusionsThese data demonstrate that long-term aspirin plus anticoagulation use is associated with a lack of aortic sac reduction and persistent type II endoleak, but not an increased risk for subsequent reintervention. Because prior studies have demonstrated that sac regression is a correlate of survival, these findings associating regression failure suggest a potential therapeutic failure for patients undergoing EVAR who also require long-term anticoagulation therapy. Although not a contraindication, long-term anticoagulation should be considered when counseling patients with a surgical indication aortic aneurysm.

Endovascular Repair In Patients With Heritable Thoracic Aortic Disease

<h3>INTRODUCTION AND OBJECTIVES</h3> In patients with heritable thoracic aortic disease (HTAD), endovascular repair of aortic aneurysm and dissection may be lifesaving but is associated with increased risk of complications. This study reports our experience with endovascular aortic and branch vessel repair in patients with HTAD. <h3>METHODS</h3> A retrospective analysis of patients with HTAD at our institution who underwent endovascular aortic and/or branch vessel repair was performed. <h3>RESULTS</h3> Twenty-nine patients with HTAD (20 male; mean age 45 ± 13 years) underwent 37 endovascular procedures between 2006-2020. Indications for repair were acute complications of aortic dissection (n=10) or aneurysm rupture (n=3), and elective aortic repair (n=18; 10 chronic dissections and 8 chronic aneurysms). Six procedures repaired branch vessel aneurysms or dissections. Twenty-five (68%) proximal landing zones were in the native vessel, 11 (30%) were in a surgical graft or elephant trunk and 1 was in an endograft. Outcomes are listed in Table I. Thirty-six (97%) procedures were technically successful and none required surgical conversion. Two patients (7%) died: one from sepsis (33 days post-procedure) and one from presumed pseudoaneurysm rupture (116 days post-procedure). Two procedures were complicated by stroke and one patient developed paraparesis. Six aortic endografts (16%) developed stent-induced new entry tears (SINEs) identified 20 ± 15 days post-procedure. Seven endografts (19%) developed a Type I endoleak and 9 (24%) developed a Type II endoleak. Within 30 days, 2 (5%) endografts required reintervention. After 30 days, 15 additional endografts (41%) required reintervention. <h3>CONCLUSIONS</h3> Endovascular repair in select patients with HTAD can manage acute and chronic complications of aortic aneurysm and dissection at relatively low risk. However, risk of endoleaks, SINEs, and reinterventions is high.

Endovascular Solutions for Aortic Arch Diseases: Total and Hybrid

Although the endovascular approach is the therapeutic option of choice for thoracic and abdominal aortic diseases, open surgery is still the treatment of choice for aortic arch diseases. While open surgical repair remains the gold standard treatment for complete aortic arch replacement, it continues to be burdened by high mortality and neurologic complications, especially for patients who require redo surgery. Therefore, in the era of endovascular surgery, it is not surprising that hybrid operating rooms, new technologies, and new approaches are strongly challenging open surgery. Less-invasive endovascular procedures, when used to treat aortic arch diseases, when feasible and indicated, have clear advantages over open surgery, primarily because there is no need for cardiopulmonary bypass, hypothermic circulatory arrest, or cerebral protection. Moreover, patients who have already been treated for acute type A aortic dissection continue to have a considerable risk for future aortic reintervention, which is associated with increased risk for short- and long-term mortality. In light of these advantages, it is clear how selected high-risk patients with aortic arch disease could benefit from the endovascular approach. However, the hemodynamic and anatomic characteristics of the aortic arch make the endovascular approach in this region challenging. In fact, uncorrected stent-graft placement can have fatal consequences for the patient and increase the risk of endoleaks and stroke. To minimize these potential risks, precise and accurate preoperative planning to achieve optimal stent-graft dimensions and implantation is essential together with careful patient selection. Endovascular options for the treatment of aortic arch disease include both hybrid procedures and total endovascular solutions. This manuscript provides an overview of the current strategies for endovascular aortic arch treatment, including the most recent available series on this topic. In addition, a literature search offers insight into the current state of the art.

Fenestrated Stent for Arch Repair for Acute Stanford Type A Aortic Dissection – A Conservative Solution for Complex Condition

Introduction: The best surgical strategy for acute Stanford type A aortic dissection (aTAAD) involving the arch is controversial. We have used a novel method that antegrade implanting a previously fenestrated stent for arch repair, which have revealed acceptable results. Methods: From December 2014 to December 2016, 81 aTAAD patients (52 male, 29 female) underwent ascending aorta replacement and fenestrated stent graft implantation. The fenestrated stent graft was implanted into the true lumen of aortic arch during the hypothermia circulation arrest period. The proximal descending aorta with the fenestration opening at the ostia of three head vessels in the arch. The proximal end of the stent graft was anastomosed to the distal end of the Dacron tube graft that replaced the proximal ascending aorta. All patients had contrast enhanced computed tomography angiography before discharge and during follow up. Results: The cardiopulmonary bypass time was 213 ± 49 minutes, aortic cross-clamp time was 133 ± 39 minutes, and selective cerebral perfusion and lower body arrest time was 27 ± 8 minutes. There were 5 in-hospital deaths due to circulation failure, multiple organ dysfunction and pulmonary infection (with the mortality of 6.2%). 5 patients died during follow-up period, the main causes of follow-up mortality were cerebral events and aortic rupture. The surviving patients had contrast enhanced CT scans in the 3rd, 6th, and 12th months. The morbidity of complication of endoleak from supraarch vessels was 5.6% (4/71), but all 4 patients were under follow-up without intervention because no dilation were discovered. The flow up CT revealed increasing false lumen thrombosis. Conclusion: In patients with aTADD, the previously fenestrated stent graft results in excellent aortic remodeling of the aortic arch and descending aorta without increasing morbidity and mortality. The risk of endoleak is maybe the underlying complication. But it will be a conservative solution for arch repair in aTAAD, especially concomitant with severe conditions. Disclosure: Nothing to disclose

Validation study of an automated algorithm to calculate the aortic angulations based on the analysis of tortuosity

The aortic angulations are associated with the risk of endoleak after EVAR. All the current methods of measurement of the angulations are based on a two- dimensional visual analysis. However, aortic reconstructions from CT acquisitions allow three-dimensional analysis of data. The aim of this study was to show that it is possible to automatically identify the significant points of curvature of the central line (CL) using an algorithm.

Development of new endovascular stent-graft system for type B thoracic aortic dissection with finite element analysis and experimental verification

Endovascular repair of the thoracic aorta with self-expanding stent-grafts has been emerging as a less invasive alternative treatment compared with conventional open surgeries. Despite the promising efficacy and safety of endovascular stent grafting, the stent-graft failure remains a major concern in terms of stent migration, device fatigue, and the risk of endoleaks. Challenges associated with the stent-grafts involve optimized geometrical structure, lifetime fatigue resistance, and adequate radial support. In this work, a novel endovascular stent-graft system is developed specially for the treatment of Stanford type B thoracic aortic dissections (TAD). Numerical study with finite element analysis (FEA) was utilized to evaluate the mechanical behaviors of the individual stent component. Results of the simulation were validated by experimental tests. Based on the systematic analysis of the parametric variations, a final stent-graft system was developed by the selection and arrangement of the individual stent components, targeting an optimal performance for treatment of TAD. The optimized solution of the stent-graft system was tested in clinical trials, showing advantageous therapeutic efficacy.

IFT15. Improved Outcomes of Thoracic Endovascular Aortic Repair Using Fenestrated Stent Graft from Zone 0 for Challenging Distal Aortic Arch Aneurysms

Thoracic endovascular aortic repair (TEVAR) using debranching or chimney techniques for distal aortic arch aneurysms cannot avoid surgical manipulation of the left common carotid artery (LCCA), which Results in a prolonged operation time with an increasing risk of stroke. Zone 0 TEVAR using a fenestrated stent graft (SG) is simple, but has a risk of endoleaks via a fenestration. We report the modified zone 0 fenestrated TEVAR. From 2007 to 2018, we have performed zone 0 TEVAR using a fenestrated SG for 74 patients with mainly degenerative distal aortic arch aneurysms located less than 15 mm away from LCCA, which is the subjects of this study. Until 2014, semi-custom-made fenestrated SG (Najuta prototype; Fig) designed to preserve blood flow into the brachiocephalic artery and LCCA had been placed from zone 0 (the control group). Since 2015, commercial SG with proximal bare stent (Valiant, Medtronic, Dublin, Ireland) has been additionally placed from zone 2 following zone 0 TEVAR using Najuta (the modified group). The left subclavian artery has been surgically reconstructed if necessary. There was no difference between the control (n = 37) and the modified group (n = 37) with ages of 78.2 and 80.0 years, aneurysms size of 60.4 and 58.4 mm, and proximal neck lengths between the LCCA and aortic aneurysm of 11.1 and 12.0 mm (Table). Early mortality rate was 0% in the both groups. The contrast-enhanced computed tomography scans at 7 days after TEVAR showed that high incident rate of type I endoleaks, from 32.4% in the control group to 5.4% in the modified group (P = .003) without increasing perioperative stroke rates (5.4%). During the follow-up period of 3 years after TEVAR, enlargement of more than 5 mm of aneurysm size was found in 9 nine (24.3%) in the control group and zero of the modified group (P = .001). There was one case of aorta-related late death in the control group. Nine aorta-related events including secondary intervention or enlargement of aneurysm occurred only in the control group. Zone 0 TEVAR using fenestrated SG (Najuta) combined with zone 2 TEVAR using Valiant with a proximal bare stent, provided significantly reduced incident of type I endoleaks via a fenestration. Zone 0 fenestrated TEVAR is a viable treatment for challenging distal aortic arch aneurysms.TableControl group (n = 37)Modified group (n = 37)P valueType I endoleaks at 7 days12 (32.4%)2 (5.4%).003Perioperative stroke2 (5.4%)2 (5.4%)1.000Survival rate at 3 years75.6 ± 7.1%91.7 ± 5.6%.304Aorta-related event-free rate at 3 years72.7 ± 7.8%100%.010 Open table in a new tab

Arterio-enteric fistula between iliac artery and cecum as an endograft complication

Endovascular treatment of aneurysms and pseudoaneurysms is more frequently employed in emergent situations since it is less invasive and has lower morbidity. Although it has excellent immediate results in regard to patency and sealing of the aneurysm, long term follow up is advised due to the risk of endoleak or graft migration. Arterio-enteric fistulas are less commonly encountered complications following endovascular procedures mostly between aorta and duodenum. Here, we present a late arterio-enteric fistula in the cecum following an endovascular repair of a pseudoaneurysm in iliac position accompanied with arterio-ureteral fistula. The patient was successfully treated by surgical approach.

Predictive value of negative initial postoperative imaging after endovascular aortic aneurysm repair

The risk of endoleak and reintervention after endovascular abdominal aortic aneurysm repair necessitates lifelong surveillance, which has associated costs, radiation exposure, and risk of nephrotoxicity. The best imaging method and timing of surveillance remain controversial. We sought to determine if a negative result of first postoperative imaging by computed tomography (CT) scan was predictive of decreased need for reintervention. We hypothesized that initial negative postoperative imaging could identify a low-risk cohort of patients who could be observed less frequently. Retrospective review of prospectively collected institutional outcomes data (2004-2009) included stratification according to postoperative imaging results. Baseline characteristics and aneurysm morphology were compared between the two groups. Cox regression analysis was used to identify risk factors predictive for endoleak-related reintervention. Kaplan-Meier survival curves were used to plot freedom from all-cause reintervention and endoleak-related reintervention for the two groups. A total of 134 patients were included in the analysis. A total of 107 patients (80%) had negative initial postoperative imaging, whereas 27 patients (20%) had evidence of an endoleak. There were no significant differences between the two groups in terms of comorbidities or anticoagulation status. Kaplan-Meier survival curves showed that there was a significant difference between those patients who had a negative initial CT scan and those who had a positive scan for endoleak in terms of both overall reintervention rates and leak-related reintervention rates. Endoleak on the first postoperative CT scan was associated with a hazard ratio of 6.37 (confidence interval, 2.02-20.10; P = .002) for leak-related reintervention and a hazard ratio of 6.01 (confidence interval, 2.24-16.17; P < .001) for all-cause reintervention. Patients with negative initial postoperative imaging were significantly less likely to require repeated interventions. These data suggest that these patients are candidates for less rigorous screening protocols.

Impact of Quantitatively Determined Native Thoracic Aortic Tortuosity on Endoleak Development After Thoracic Endovascular Aortic Repair

The objective of our study was to assess whether there is an association between native thoracic aortic curvature and the development of endoleaks after thoracic endovascular aortic repair. Quantitative analysis of the native aortic lumen was performed on preprocedural CT angiograms of 40 patients with thoracic aortic aneurysm treated by thoracic endovascular aortic repair. The curvature of the median centerline was measured. Tortuosity indexes were calculated on the basis of the sum of the curvature values within the diseased segment and in the proximal and distal fixation zones. The association between the tortuosity index and endoleak was analyzed. Compared with patients without endoleaks, the tortuosity index of the proximal fixation zone was higher in patients with type Ia endoleak (9.5 vs 1.5 cm(-1), p < 0.01); the tortuosity index of the distal fixation zone was higher in type Ib endoleak patients (6.6 vs 0.5 cm(-1), p < 0.05); and the tortuosity indexes of the proximal fixation zone and of the diseased segment were higher in type III endoleak patients (11.0 vs 1.5 cm(-1), p < 0.01; and 15.8 vs 7.2 cm(-1), p < 0.01, respectively). Patients with a type III endoleak had longer diseased segments and larger mean diameters of the aneurysm than patients without endoleaks (148.6 vs 87.1 mm, p < 0.01; and 75.4 vs 63.2 mm, p < 0.05, respectively). Logistic regression analysis revealed that the risk of a type I or type III endoleak increased as the tortuosity index increased, with a 90% risk of endoleak at a tortuosity index of 10 cm(-1) in the proximal fixation zone. Quantification of aortic tortuosity using CT angiograms may help to predict whether an endoleak will develop after thoracic endovascular aortic repair, and this quantification method may become an important tool for risk stratification before thoracic endovascular aortic repair.

Aneurysm Sac Pressure Measurement with a Pressure Sensor in Endovascular Aortic Aneurysm Repair

Aortic endograft surveillance is a necessity for the lifetime of a patient owing to the risk of endoleaks and device complications. The current standard of care for surveillance is radiologic imaging. The most commonly used modality is computed tomographic angiography. Magnetic resonance angiography and ultrasonography have also been used as surveillance tools. These imaging techniques have risks and limitations, and alternative surveillance tools are being investigated. Remote pressure sensing is a promising technology that can provide adjunctive support to the current imaging modalities. The technology is applicable to both abdominal and thoracic endograft implantation and surveillance. It has recently gained clearance from the US Food and Drug Administration for acute aneurysm exclusion during an abdominal endograft insertion. As more data are accumulated, it may be possible for remote pressure sensing to replace current imaging techniques as the sole modality for endograft surveillance.

Midterm Follow-up of a Single-center Experience of Endovascular Repair of Abdominal Aortic Aneurysms with Use of the Talent Stent-Graft

To review the midterm results of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) with the Talent stent-graft. All patients who underwent EVAR of AAAs with Talent stent-grafts from February 1998 to April 2002 at a single institution were monitored for a minimum of 2 years or until an endpoint of death or rupture was reached. There were 68 eligible patients, who were monitored for a mean period of 39 months (range, 24-72 months). Forty-nine (72.9%) were alive at 2 years; among the 19 deaths, two resulted from aneurysm rupture and the other 17 were unrelated to EVAR. There was one immediate conversion to open repair and five primary proximal endoleaks; the remaining 62 patients (91.2%) all had a technically successful procedure. There were 33 endoleaks during follow-up: 23 (69.7%) were treated conservatively and 10 (30.3%) underwent secondary intervention in the form of embolization (n=2), attempted embolization (n=2), endovascular stent-graft placement (n=3), combined stent-graft placement and embolization (n=1), or surgical conversion (n=2). Overall, there were five persistent endoleaks, and the remaining patients were free of endoleak at their last review or endpoint. Three stent-grafts migrated and required further endovascular intervention. Wire fracture was seen in two stents but presented no clinical sequelae. There was one case of graft limb thrombosis that required surgical thrombectomy. EVAR of AAAs with use of the Talent stent-graft is a promising and acceptable alternative to open surgery. Our 30-day mortality rate of zero compares extremely well with historical data from open surgery and the findings of more recently published trials. The risk of endoleak and uncertainty over durability require long-term surveillance.

Interventional techniques in the treatment of aortic dissection

Acute aortic dissection continues to be one of the most catastrophic cardiovascular events. While there is a general consensus on immediate surgical repair when the ascending aorta is involved, the optimal treatment strategy for type B aortic dissection (B-AD) remains controversial. Recently, endovascular treatment with percutaneous stent-graft implantation, originally used for aortic aneurysm exclusion, has acquired an important role in the treatment of B-AD. Imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI) and angiography have a fundamental role in the search for the anatomic details necessary to tailor the stent graft and in evaluating the most suitable anatomy for stent graft. Transesophageal echocardiography is fundamental during the procedure to monitor the correct release of the stent graft and evaluate the result of the procedure expressed by immediate thrombosis out of the stent-graft. Again, imaging techniques, more notably CT, have a fundamental role in the postoperative followup after stent-graft placement. The risk of endoleaks may compromise the result of endovascular repair and increase the risk of aortic rupture. Several reports and a few trials attesting to technical feasibility and safety of stent-graft implantation procedures for B-AD have been reported so far. Also, a randomised trial comparing type B aortic stent-graft placement with medical therapy is currently underway. According to the investigators, new therapeutic indications are likely to emerge also in uncomplicated B-AD.