Standard Endovascular Aneurysm Repair Research Articles

Machine Learning Based Prediction of Post-operative Infrarenal Endograft Apposition for Abdominal Aortic Aneurysms

Challenging infrarenal aortic neck characteristics have been associated with increased risk of a type Ia endoleak after endovascular aneurysm repair (EVAR). Short apposition (< 10 mm circumferential shortest apposition length [SAL]) on the first post-operative computerised tomography angiography (CTA) has been associated with type Ia endoleak. Therefore, this study aimed to develop a model to predict post-operative SAL in patients with an abdominal aortic aneurysm based on the pre-operative shape. A statistical shape model was developed to obtain principal component scores. The dataset comprised patients treated with standard EVAR without complications (n = 93) enriched with patients with a late type Ia endoleak (n = 54). The infrarenal SAL was obtained from the first post-operative CTA and subsequently binarised (< 10 mm and ≥ 10 mm). The principal component scores that were statistically different between the SAL groups were used as input for five classification models, and evaluated by means of leave one out cross validation. Area under the receiver operating characteristics curves (AUC), accuracy, sensitivity, and specificity were determined for each classification model. Of the 147 patients, 24 patients had an infrarenal SAL < 10 mm and 123 patients had a SAL ≥ 10 mm. The gradient boosting model resulted in the highest AUC of 0.77. Using this model, 114 (78.0%) patients were correctly classified; sensitivity (< 10 mm apposition was correctly predicted) and specificity (≥ 10 mm apposition was correctly predicted) were 0.70 and 0.79, and were based on a threshold of 0.21, respectively. A model was developed to predict which patients undergoing EVAR will achieve sufficient graft apposition (≥ 10 mm) in the infrarenal aortic neck based on a statistical shape model of pre-operative CTA data. This model can help vascular specialists during the planning phase to accurately identify patients who are unlikely to achieve sufficient apposition after standard EVAR.

Clinical and Radiological Outcomes of Accessory Renal Artery Exclusion during Endovascular Repair of Abdominal Aortic Aneurysms.

Accessory renal arteries (ARAs) frequently coexist with abdominal aortic aneurysms (AAA) and can influence treatment. This study aimed to retrospectively analyze the ARA's exclusion effect on patients undergoing standard endovascular aneurysm repair for AAA. The study focused on medium- and long-term outcomes, including type II endoleak, aneurysmal sac changes, mortality, reoperation rates, renal function, and infarction post-operatively. 76 patients treated with EVAR for AAA were included. One hundred and two ARAs were identified: 69 originated from the neck, 30 from the sac, and 3 from the iliac arteries. The ARA treatment was embolization in 15 patients and coverage in 72. Technical success was 100%. One-month post-operative computed tomography angiography (CTA) revealed that 76 ARAs (74.51%) were excluded. Thirty-day complications included renal deterioration in 7 patients (9.21%) and a blood pressure increase in 15 (19.73%). During follow-up, 16 patients (21.05%) died, with three aneurysm-related deaths (3.94%). ARA-related type II endoleak (T2EL) was significantly associated with the ARA's origin in the aneurysmatic sac. Despite reinterventions were not significantly linked to any factor, post-operative renal infarction was correlated with an ARA diameter greater than 3 mm and ARA embolization. ARAs can influence EVAR outcomes, with anatomical and procedural factors associated with T2EL and renal infarction. Further studies are needed to optimize the management of ARAs during EVAR.

Intraoperative Staff Radiation Exposure During Aortic Endovascular Procedures

The risk of radiation exposure in the surgical operating room (OR) and/or catheterization laboratory is now well established. Complex endovascular procedures often require multiple approaches and different positioning of the staff members around the patient, potentially increasing the levels of radiations exposure. Our goal was to evaluate the levels of radiation exposure of the members of the staff during endovascular aortic procedures in order to propose radioprotection optimization. We included 41 aortic endovascular procedures out of 114 procedures performed between January 12, 2014, and August 31, 2015, including 24 standard endovascular aortic aneurysm repair (EVAR), 7 EVAR with iliac branch (EVARib), 8 complex fenestrated/branched EVAR (F/B EVAR), and 2 thoracic EVAR (TEVAR). Procedures were performed in an OR equipped with a carbon fiber table and a mobile fluoroscopy C-arm. We collected the usual dosimetry data given by the C-arm as well as the patient's peak skin dose (PSD). In all staff members, radiation exposure was measured with thermoluminescent chip dosimeters placed on both temples, on posterior sides of both hands, and on both lower legs. PSD levels were low for EVAR because 24 patients had values below the reading threshold. PSD significantly increased with more complex procedures. Main operator (MO) received the higher level of irradiation on whole body, hands, and ankles. Eye lenses irradiation was higher on both assistant operators (AOs). Other members received low levels of irradiation. We found a high ranges of radiation exposure with a high risk of exposure for the AO, mainly for F/B EVAR and EVARib. Even if all personal protections are used, staff positioning is a major point that must be considered. If MO is supposed to be the most exposed to X-rays, specific conditions of positioning of the AO may be at risk of exposure.

Outcomes of standard EVAR for juxtarenal abdominal aortic aneurysm in patients unsuitable for fenestrated EVAR and open repair.

To evaluate the long-term outcomes of standard endovascular aneurysm repair (S-EVAR) of juxtarenal abdominal aortic aneurysms (JAAAs). Data of patients with JAAAs who were unsuitable for fenestrated endovascular aneurysm repair (F-EVAR) and open repair (OR) and underwent treatment from January 2015 to December 2021 were retrospectively reviewed. Computed tomography angiography and ultrasonography of the aorta were performed before discharge, at 6 and 12months postoperatively, and annually thereafter. The main outcome measures were mortality, type Ia endoleaks, and reintervention. A total of 62 patients (mean age, 72.1 ± 7.3years) underwent S-EVAR. The mean aneurysm length and diameter and the proximal neck length and diameter were 110.4 ± 30.9mm, 57.2 ± 15.9mm, 8.09 ± 0.97mm, and 26.05 ± 0.49mm, respectively. The mean suprarenal and infrarenal aortic angles were 162.9 ± 26° and 144.1 ± 31°, respectively. The mean follow-up duration was 40.6 ± 23.4 months and the 5-year survival rate was 62.2%. Six (9.8%) patients experienced type Ia endoleaks, of whom three underwent endovascular repair at 12, 18, and 24months, one underwent conversion to OR for AAA rupture at 7days and died, two had minor endoleaks and were kept under observation, and one declined reintervention at 36months. The 5-year freedom from reintervention rate was 84.4%. The aneurysm diameter shrank in 50 cases (81%), remained stable in 5 cases (8%), and increased in 7 cases (11.3%). A suprarenal aortic angle <114° was associated with type Ia endoleak (p = .005). In patients unsuitable for F-EVAR and OR and with a suprarenal aortic angle >114°, the use of S-EVAR for JAAAs can be considered safe and effective. In this study, early and long-term postoperative outcomes demonstrated that S-EVAR achieved satisfactory results in the prevention of aneurysm rupture and associated mortality.

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.

Endovascular aneurysm repair under local anesthesia through bilateral percutaneous femoral access is a safe strategy to improve early outcomes and reduce hospital stay.

To estimate the impact of anesthetic conduct, alone and in combination with the type of femoral access, on early results after endovascular aneurysm repair (EVAR). A retrospective multicenter analysis on patients undergoing elective standard EVAR at four academic centers was performed. Patients undergoing the procedure through either local or general anesthesia were compared. Comparative subanalyses of the two groups were performed for the type of femoral access to evaluate further impact on outcomes. Five hundred twenty-four patients underwent elective standard EVAR, of which 207 (39.5%) under general anesthesia and 317 (60.5%) under local anesthesia. Patients who underwent general anesthesia had higher 30-day mortality rates (3.4% vs. 0.3%, P=0.005), as well as slightly worse 30-day major systemic complication rates (8.2% vs. 5.4%, P=0.195). There were no differences in terms of reinterventions (2.1% vs. 2.5%, P=0.768) and aneurysm-related mortality (0% vs. 0.4%, P=0.422) at one year. Total intervention times were significantly longer in the general anesthesia group (126 vs. 89 minutes, P=0.001), as well as the total length of hospital stay (7.6 vs. 5.3 days, P=0.007). At subanalyses, the combination of local anesthesia with bilateral percutaneous femoral access further improved 30-day outcomes and determined an additional reduction in total intervention times and ICU stays. EVAR performed under local anesthesia has a significantly better impact on early results when compared to general anesthesia. Combining percutaneous bilateral femoral access to local anesthesia reduced procedural times, ICU stays and consequently improved early results.

Editor's Choice – Comparison of Open Surgery and Endovascular Techniques for Juxtarenal and Complex Neck Aortic Aneurysms: The UK COMPlex AneurySm Study (UK-COMPASS) – Peri-operative and Midterm Outcomes

Treatment of juxtarenal and complex neck abdominal aortic aneurysms (AAAs) is now commonly by endovascular rather than open surgical repair (OSR). Published comparisons show poor validity and scientific precision. UK-COMPASS is a comparative cohort study of endovascular treatments vs. OSR for patients with an AAA unsuitable for standard on label endovascular aneurysm repair (EVAR). All procedures for AAA in England (November 2017 to October 2019) were identified, AAA anatomy assessed in a Corelab, peri-operative risk scores determined, and propensity scoring used to identify patients suitable for either endovascular treatment or OSR. Patients were stratified by aneurysm neck length (0 - 4 mm, 5 - 9 mm, or ≥ 10 mm) and operative risk; the highest quartile was considered high risk and the remainder standard risk. Death was the primary outcome measure. Endovascular treatments included fenestrated EVAR (FEVAR) and off label standard EVAR (± adjuncts). Among 8 994 patients, 2 757 had AAAs that were juxtarenal, short neck, or complex neck in morphology. Propensity score stratification and adjustment method comparisons included 1 916 patients. Widespread off label use of standard EVAR devices was noted (35.6% of patients). The adjusted peri-operative mortality rate was 2.9%, lower for EVAR (1.2%; p= .001) and FEVAR (2.2%; p= .001) than OSR (4.5%). In standard risk patients with a 0 - 4 mm neck, the mortality rate was 7.4% following OSR and 2.3% following FEVAR. Differences were smaller for patients with a neck length ≥ 5 mm: 2.1% OSR vs. 1.0% FEVAR. At 3.5 years of follow up, the overall mortality rate was 20.7% in the whole study population, higher following FEVAR (27.6%) and EVAR (25.2%) than after OSR (14.2%). However, in the 0 - 4 mm neck subgroup, overall survival remained equivalent. The aneurysm related mortality rate was equivalent between treatments, but re-intervention was more common after EVAR and FEVAR than OSR. FEVAR proves notably safer than OSR in the peri-operative period for juxtarenal aneurysms (0 - 4 mm neck length), with comparable midterm survival. For patients with short neck (5 - 9 mm) and complex neck (≥10mm) AAAs, overall survival was worse in endovascularly treated patients compared with OSR despite relative peri-operative safety. This warrants further research and a re-appraisal of the current clinical application of endovascular strategies, particularly in patients with poor general survival outlook owing to comorbidity and age.

Local Anesthesia for Endovascular Repair of Abdominal Aortic Aneurysm Allows for Accurate Graft Deployment with Durable Results

ObjectiveLocal anesthesia (LA) is sparsely used in endovascular aneurysm repair (EVAR) despite short term benefit, likely secondary to concerns over patient movement preventing accurate endograft deployment. The objective of this study is to examine the association between anesthesia type and endoleak, sac regression, reintervention, and mortality. MethodsThe Vascular Quality Initiative database was queried for all EVAR cases from 2014-2022. Patients were included if they underwent percutaneous elective EVAR with anatomical criteria within instructions for use of commercially approved endografts. Multivariable logistic regression with propensity score weighting lysis was used to determine the association between anesthesia type on the risk of any endoleak noted by intra-operative completion angiogram and sac regression. Multivariable survival analysis with propensity score weighting was used to determine the association between anesthesia type and endoleak at 1 year, long-term reintervention and mortality. Results13932 EVARs met inclusion criteria: 1075 (8%) LA and 12857 (92%) general anesthesia (GA). On completion angiogram, LA was associated with fewer rates of any endoleaks overall (16% vs 24%, p<0.001). On multivariable analysis with propensity score weighting, LA was associated with similar adjusted odds of any endoleak on intra-operative completion angiogram (OR 0.56, 95%CI 0.47-0.68) as well as combined type 1a and type 1b endoleaks (OR 0.72, 05%CI 0.47-1.09). Follow-up computed tomography imaging at 1 year was available for 4892 patients, 377 (8%) LA and 4515 (92%) GA. At 1 year, LA was associated similar rate of freedom from any endoleaks compared to GA (0.66 (95%CI 0.63-0.69) vs 0.71 (95%CI 0.70-0.72), p=0.663) and increased rates of sac regression (50% vs 45% p=0.040). On multivariable analysis with propensity score weighting, LA and GA were associated with similar adjusted odds of sac regression (OR 1.22, 05%CI 0.97-1.55). LA and GA had similar rates endoleak at 1 year (HR 0.14, 95%CI 0.63-1.07), however LA was associated with decreased hazards of combined type 1a and 1b endoleaks at 1 year (HR 0.87, 95%CI 0.80-0.96). LA and GA had similar adjusted long-term reintervention rate (HR 0.77, 95%CI 0.44-1.38) and long-term mortality (HR 1.100, 95%CI 079-1.25). ConclusionLA is not associated with increased adjusted rates of any endoleak on completion angiogram or at 1-year follow-up compared to GA. LA is associated with decreased adjusted rates of yype 1a and type1b endoleak at 1 year, but similar rates of sac regression, long term reintervention and mortality. Concerns for accurate graft deployment should not preclude use of LA and LA should be increasingly considered when deciding on anesthetic type for standard elective EVAR.

Use of EndoAnchors during index endovascular aortic aneurysm repair in patients with hostile proximal aortic neck anatomy.

Standard endovascular aortic aneurysm repair (EVAR) is sometimes the only treatment option for patients with hostile aortic neck anatomy, but it carries an increased risk of both early and late procedure-related complications. The aim of this study was to report on single-center experience with the Heli-FX EndoAnchors (Medtronic, Santa Rosa, CA) as an adjunctive procedure to endovascular aneurysm repair (EVAR) for prevention and perioperative treatment of proximal neck complications in patients with hostile neck anatomy. MATERIALS AND METHODS:Asingle-centre, retrospective study evaluating 24 consecutive patients treated with EndoAnchors during the index EVAR procedure between November 2018 and August 2021. EndoAnchor implantation was indicated for cases with hostile proximal aortic neck anatomy characterised by the presence of at least one of the following parameters: length of 28 mm, angle of >60°, circumferential thrombus/calcification involving ≥50%, and reverse taper. Median follow-up period was 22.5 months (IQR 2-31.5 months) with no aneurysm-related death, rupture, or conversion to open surgical repair during the follow-up. The procedural success rate was 100%, with no type Ia endoleak at the completion angiography. Amean of 7 EndoAnchors was used per patient (range 4-12). There were no EndoAnchor fractures and dislocations or stent graft fabric damage due to anchor implants.Twenty-three patients (95.8%) remained free of type Ia endoleak and migration on follow-up imaging. Aneurysm sac regression was observed in 13 patients (54.1%), while in 8 patients (33.3%) the sac remained stable. Sac enlargement was present in 1 patient (4.2%) due to late type Ia endoleak. Twopatients were lost to the follow-up immediately after the procedure.Between two groups of patients (sac regression versus failure to regress), the larger initial diameter of the proximal neck was the only significant independent factor associated with a lower possibility of sac regression (p= 0,021). The use of EndoAnchors during the index EVAR procedure in cases with challenging aortic neck anatomy with or without perioperative type Ia endoleak was associated with good midterm results and led to sac regression in most of the patients (Tab. 4, Fig. 3, Ref. 31).

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.

Editor's Choice – Radiation Dose Reduction During Contralateral Limb Cannulation Using Fiber Optic RealShape Technology in Endovascular Aneurysm Repair

The increasing number of endovascular procedures has resulted in an increasing radiation burden, particularly for the treatment team. Fiber Optic RealShape (FORS) technology uses laser light instead of fluoroscopy to visualise the endovascular guidewire and catheters. These devices can be used during the navigational part of procedures, such as cannulation of the contralateral limb (CL) in endovascular aneurysm repair (EVAR). The aim of this study was to describe the effect of using FORS on radiation dose during CL cannulation in standard EVAR. This was a non-randomised, retrospective comparison study of prospectively collected, single centre data from FORS guided EVAR compared with a conventional fluoroscopy only guided EVAR cohort. A total of 27 FORS guided cases were matched 1:1 based on sex, age, and body mass index (BMI) with 27 regular (fluoroscopy only) EVARs. This study primarily focused on (1) technical success of FORS and (2) navigation time and radiation dose (cumulative air kerma [CAK], air kerma area product [KAP], and fluoroscopy time [FT]) during cannulation of the CL. In addition, overall procedure time and radiation dose of the complete EVAR procedure were studied. In 22 (81%) of the 27 FORS guided cases the CL was successfully cannulated using FORS. All radiation dose parameters were significantly lower in the FORS group (CAK, p < .001; KAP, p= .009; and FT, p < .001) for an equal navigation time (p= .95). No significant differences were found when comparing outcomes of the complete procedure. Use of FORS technology significantly reduces radiation doses during cannulation of the CL in standard EVAR.

Initial two-day blood pressure management after endovascular aneurysm repair improves midterm outcomes by reducing the incidence of early type II endoleak

ObjectiveThe aim of this study was to evaluate midterm outcomes of our novel strategy of postoperative initial 2-day blood pressure management (BPM) after endovascular aneurysm repair (EVAR) for the prevention of subsequent type II endoleak (T2EL) in a single-center series. MethodsBetween 2008 and 2014, 137 patients who underwent EVAR for abdominal aortic aneurysm (AAA) were reviewed. Starting from 2013, the mean blood pressure was maintained between 75 and 90 mmHg for the initial 24 hours after EVAR followed by systolic pressure controlled below 120 mmHg during the next 24 hours in the treatment group (n = 76). The incidence of T2EL detected at 7 days, reintervention, and AAA sac diameter up to 5 years after EVAR were compared with those of the control group comprising of 60 consecutive patients who underwent standard EVAR without BPM prior to 2013. ResultsBetween the treatment group and the control group, significant differences were achieved in the incidence of T2EL at 7 days (19.7% vs 40.0%; P = .009), a mean decrease of AAA sac diameter at 1-year (−5.1 ± 4.9 vs −2.2 ± 6.7 mm; P = .013) and 2-year (−5.4 ± 7.7 vs −1.7 ± 10.8 mm; P = .045). In addition, there was a significant decrease in the incidence of T2EL detected at 7 days with the use of the Gore Excluder with 22.7% in the treatment group vs 80.0% in the control group (P < .001), which resulted in a significant decrease in the aneurysm sac diameter up to 4 years after EVAR. Survival rate without AAA sac enlargement at 5 years after EVAR (83.0% vs 70.0%; P = .021) in the treatment group was significantly higher than that of the control group, whereas no significant differences were observed in the freedom rates of reintervention, T2EL-related reintervention, and all-cause mortality between the groups. ConclusionsPostoperative initial 2-day BPM had a preventive effect on AAA sac enlargement until midterm periods, by reducing the incidence of T2EL at 7 days after EVAR. The usage of Gore Excluder under BPM was especially associated with sustained positive effects until the midterm follow-up.

Outcome Analysis of Speed Gate Cannulation during Standard Infrarenal Endovascular Aneurysm Repair.

Endovascular aortic repair (EVAR) is generally performed with bi/trimodular stent-grafts requiring retrograde contralateral gate cannulation (CGC). In the case of tricky CGC, an increased EVAR procedural time and radiation exposure have been reported. Herein, we compare the outcomes of conventional CGC and CGC using the speed gate cannulation (SGC) technique in standard EVAR for a propensity-matched cohort. A total of 371 patients were retrospectively analyzed. Inclusion criteria were fulfilled in 172 patients who underwent propensity score matching. Primary outcomes included operative time, CGC time, mean contrast medium, fluoroscopy time, and CGC fluoroscopy time. After matching, 78 patients were included in each group (SGC vs. standard). Primary outcomes registered a significant reduction in CGC time (4 [1-6] vs. 8 [6-14] min; p = 0.001) and fluoroscopy time (12 [9-16] vs. 17 [12-25] min). In this preliminary experiment, the use of SGC was feasible with no significant registered postoperative complications. A significant reduction in contrast medium usage, radiation exposure, and CGC time was observed with the use of SGC. SGC is a simple adjunctive technique, and its use should be considered in standard EVAR, especially in emergency scenarios, where time is of the essence.

Post-Implantation Syndrome Incidence is Higher After Complex Endovascular Aortic Procedures Than After Standard Infrarenal Repair

Post-implantation syndrome (PIS), characterised by malaise, fever, and increased inflammatory markers, is a common occurrence after endovascular aneurysm repair (EVAR), causing prolonged hospitalisation and increased cost. This study aimed to determine the incidence and short-term outcomes of PIS after fenestrated or branched procedures in aorto-iliac aneurysms compared with standard EVAR. A retrospective, comparative study from a tertiary academic institution was undertaken. All patients who underwent elective EVAR with polyester stent grafts from January 2015 to June 2021 were considered. Two groups were defined: standard EVAR (sEVAR) and complex EVAR (cEVAR). The latter included visceral fenestrated and branched or iliac branch and chimney stent grafts. The primary outcome was the incidence of PIS within three days of the index procedure. Secondary outcomes were short-term complications and risk factors for PIS. A multivariable model was constructed to correct for confounders. Overall, 253 patients were included: 165 (65.2%) sEVAR and 88 (34.8%) cEVAR. Complex EVAR patients were younger, with larger aneurysms, had longer procedures, and were more likely to have intra-operative complications. The PIS incidence was 23.7% (n= 60), significantly higher in cEVAR (34.1% vs. 18.2%; p= .005) and increased with the complexity of the procedure (EVAR: 18.2% vs. EVAR+iliac branch device: 25.0% vs. fenestrated and branched EVAR: 36.2%; p= .030). On multivariable analysis, cEVAR (OR 2.833, 95% CI 1.295 - 6.198; p= .009) was associated with a significantly increased risk of PIS. No differences in short term outcomes according to PIS status were noted. Group sub-analysis for cEVAR patients did not reveal any statistically significantly different outcomes according to PIS occurrence. In this cohort, cEVAR procedures were associated with a significantly increased risk of developing PIS compared with standard infrarenal repair. Post-implantation syndrome also appears to have a benign course with no major impact on peri-operative outcomes after cEVAR. Further research to confirm these findings is required.

Possible implications of device-specific variability in post-endovascular aneurysm repair sac regression and endoleaks for surveillance categorization

ObjectiveSignificant sac regression during early surveillance has been shown to best predict reintervention-free long-term surveillance after endovascular aneurysm repair (EVAR). Furthermore, a persistent endoleak has been related to a worse outcome. Individualized surveillance algorithms based on these findings have been suggested. There are no studies comparing the performance of different stent grafts regarding sac regression, the presence of type II endoleaks, and their possible implications for individualized surveillance. The objective of this study was to evaluate device-specific differences and how these may affect patient categorization for surveillance. MethodsPatients were treated electively with standard EVAR between 2005 and 2015 using three different devices (Zenith by Cook, Excluder by Gore, and Endurant by Medtronic). The data were reviewed retrospectively until 2020. Patients’ computed tomography angiographies (CTAs) at 30 days and at 2 years were analyzed for freedom from endoleaks and for sac regression of ≥5 mm. Reinterventions during long-term surveillance were counted. Patients were categorized according to the presence of any endoleak and sac regression at 30 days and 2 years, and the probability of reintervention-free long-term surveillance was evaluated based on these findings. ResultsA total of 435 patients were treated for an abdominal aortic aneurysm with EVAR during the study period. At 30 days, 80.0% (n = 339) of the patients were free from endoleaks, and at 2 years, 78.9% (n = 273) were free from endoleaks. There was a significant difference in endoleak rate at 30 days and 2 years between the devices (P < .001 and P = .001). There was no significant difference in sac regression between the devices at 2 years (P = .096). The categorization at 30 days based on endoleak status had a sensitivity of 44.9%, specificity of 87.4%, and negative predictive value of 84.1% for finding a reintervention-requiring complication during long-term follow-up. The corresponding figures at 2 years were 63.3%, 91.4%, and 89.4%, respectively. The combination of freedom from endoleaks and sac regression of ≥5 mm in the 2-year CTA best predicted an uneventful long-term surveillance. Patients who met this criterion had a 95.6% probability (negative predictive value) of having a reintervention-free long-term surveillance. ConclusionsThere are significant differences in the prevalence of endoleaks between devices at 30 days and 2 years, but there is no difference in sac regression. Patients with sac regression of ≥5 mm and no endoleaks in the 2-year CTA can be safely categorized for infrequent surveillance regardless of the stent graft model that has initially been used.

Carbon Dioxide Guided Endovascular Aortic Aneurysm Repair in Impaired Renal Function: Propensity Score Matched Study

Carbon dioxide (CO2) is the preferred contrast agent in patients with impaired renal function and or contrast allergy and, particularly, in patients who require large volumes of contrast for complex endovascular procedures. In this study, the aim was to clarify the possible protective effects of CO2 guided endovascular aneurysm repair (EVAR) for patients with impaired renal function by propensity score matching. A retrospective analysis of the database was performed for 324 patients having EVAR between January 2019 and January 2022. A total of 34 patients treated with CO2 guided EVAR were evaluated. This cohort was matched for age, sex, pre-operative serum creatinine levels and glomerular filtration rate (GFR) levels and specific comorbidities to obtain homogeneous groups that included only patients with impaired renal function (eGFR < 60 mL/min/1.73m2). The primary endpoint was to compare the decrease in eGFR from baseline and development of contrast induced nephropathy (CIN) using propensity score matching. Secondary endpoints were the need for renal replacement therapy, other peri-procedural morbidity and mortality. Thirty-one patients (9.6%) of the total population developed CIN. There was no difference in the rate of CIN development between the standard EVAR group and the CO2 guided EVAR group in the unmatched population (10% vs. 3%, p= .15). After matching, the decrease in eGFR values after the procedure was more pronounced for the standard EVAR group (from 44 to 40 mL/min/1.73m2, interaction p= .034). Meanwhile, CIN development was more frequent for the standard EVAR group (24% vs. 3%, p= .027). In matched patients, early death did not differ between the groups (5.9% vs. 0, p= .15) CONCLUSION: Patients with impaired renal function are at higher risk of CIN after an endovascular procedure. CO2 guided EVAR is a safe, effective, and feasible treatment option, especially for patients with impaired renal function. CO2 guided EVAR may be a protective measure for contrast induced nephropathy.

Endovascular Solutions for Abdominal Aortic Aneurysms: Fenestrated, Branched and Custom-Made Devices.

Abdominal aortic aneurysm (AAA) has a prevalence of 4.8%. AAA rupture is associated with significant mortality, thus surgical intervention is generally required once the aneurysm diameter exceeds 5.5cm. Endovascular aneurysm repair (EVAR) is the predominant repair modality for AAA. However, in patients with complex aortic anatomy, fenestrated or branched EVAR is a superior repair option vs standard EVAR. Fenestrated and branched endoprostheses can be off-the-shelf or custom-made, which offers a more individualised approach. To summarise and evaluate the clinical outcomes achieved by fenestrated EVAR (FEVAR) and branched EVAR (BEVAR), and to explore the role of custom-made endoprostheses in contemporary AAA management. A literature search using Ovid Medline and Google Scholar was conducted to identify literature pertaining to the use and outcomes of fenestrated, branched, fenestrated-branched and custom-made endoprostheses for AAA repair. FEVAR is an effective repair modality for patients with AAA that offers similar early survival, improved early morbidity but higher rates of reintervention in comparison to open surgical repair (OSR). Compared with standard EVAR, FEVAR is associated with similar in-hospital mortality yet higher rates of morbidity, especially regarding renal outcomes. BEVAR outcomes are rarely reported exclusively in the context of AAA repair. When reported, BEVAR is an acceptable alternative to EVAR in the treatment of complex aortic aneurysms and has similar reported complication issues to FEVAR. Custom-made grafts are a good alternative treatment option for complex aneurysms where hostile aneurysm anatomy precludes the use of conventional EVAR and sufficient time is available for the manufacturing of such devices. FEVAR offers a very effective treatment for patients with complex aortic anatomy and has been well-characterised over the past decade. RCTs and longer-term studies are desirable for unbiased comparison of non-standard EVAR modalities.

The prognostic value of preoperative systemic inflammation-based scoring in patients undergoing endovascular repair of abdominal aortic aneurysm

ObjectiveAbdominal aortic aneurysm (AAA) is a common condition that is predominantly managed in the United Kingdom by endovascular aneurysm repair (EVAR). Activation of the systemic inflammatory response (SIR) appears to offer prognostic value in patients with vascular disease. The present study examines the relationship between the SIR and survival in patients undergoing standard and complex endovascular aneurysm repair (EVAR and fenestrated/branched [F/B]-EVAR). MethodsConsecutive patients undergoing elective EVAR and F/B-EVAR were retrospectively identified from three tertiary vascular centers over a 5-year period. Neutrophil:lymphocyte ratio and modified Glasgow Prognostic Score were calculated from preoperative blood results and combined into the systemic inflammatory grade (SIG). The primary outcome was all-cause mortality during the follow-up period, which was compared between subgroups of SIGs. ResultsThere were 506 patients included in the final study, with a median follow-up of 68.0 months (interquartile range, 27.3 months), and there were 163 deaths during the follow-up period. Mean survival in the SIG 0 vs SIG 1 vs SIG 2 vs SIG 3 vs SIG 4 subgroups was 80.7 months (95% confidence interval [CI], 76.5-85.0 months) vs 78.7 months (95% CI, 72.7-84.7 months) vs 61.0 months (95% CI, 51.1-70.8 months) vs 65.1 months (95% CI, 45.0-85.2 months) vs 54.9 months (95% CI, 34.4-75.3 months) (P < .05). In the entire cohort, age (P < .001), body mass index (P < .05), high creatinine (P < .05), and SIG (P < .05) were associated with survival on univariate analysis, with retained independent association for age (hazard ratio, 1.72; 95% CI, 1.29-2.31; P < .001) and SIG (hazard ratio, 1.20; 95% CI, 1.02-1.40; P < .05) on multivariate analysis. Increasing SIG (area under the curve, 0.68; 95% CI, 0.58-0.78; P < .01) predicted 1-year mortality. ConclusionsMarkers of the SIR such the SIG may be used to identify patients at higher risk of adverse outcome in patients undergoing EVAR and F/B-EVAR for abdominal aortic aneurysms. These findings warrant further investigation in large prospective cohort studies.

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.

A Scoping Review on the Incidence, Risk Factors, and Outcomes of Proximal Neck Dilatation after Standard and Complex Endovascular Repair for Abdominal Aortic Aneurysms.

Background: To define proximal neck dilation (PND) after standard endovascular aneurysm repair (EVAR) and fenestrated EVAR (FEVAR), determining: incidence and risk factors; evidence base that links PND to outcomes of patients; recurring themes or gaps in the literature. Methods: We performed a scoping review and included only full-text English articles with follow-up focusing on PND in patients undergoing EVAR or FEVAR, published between 2000 and 2022. The following PICO question was used to build the search equation: in patients with abdominal-aortic-aneurysm (AAA) (Population) undergoing endovascular repair (Intervention), what are the incidence, risk factors and prognosis of radiologically defined PND (Comparison) on short-term and long-term outcomes (Outcomes)? Results: 15 articles were included after review. Measurement protocols for proximal aortic neck (PAN) varied among individual studies and the definition of PND resulted as heterogeneous. Rate of patients with a PND ranged between 0% and 41%. Large proximal neck (>28 mm) and excessive graft sizing (30%) were predictors for PND. New endografts with low outward radial forces and FEVAR seemed to be protective. Surgical conversion was the definitive option in the case of patients unfit for other endovascular treatments. Conclusions: PND is a frequent finding after EVAR and FEVAR. Excessive graft oversizing and large baseline PAN were predictors of neck enlargement, independently by the type of standard endograft used. FEVAR may be considered protective against complications, together with endografts using low outward radial forces. Lifelong radiological follow-up is mandatory.