Time Of Endovascular Aneurysm Repair Research Articles

Prophylactic Perigraft Arterial Sac Embolization During EVAR: Minimizing Type II Endoleaks and Improving Sac Regression

Type II endoleaks (ELII) are the most common complication following endovascular aneurysm repair (EVAR). Persistent type II endoleaks require continual surveillance and have been shown to increase the risk of Type I and III endoleaks, sac growth, need for intervention, conversion to open or even rupture directly or indirectly. These are often difficult to treat following EVAR and there are limited data regarding the effectiveness of prophylactic treatment of ELII. The aim of this study is to report midterm outcomes of prophylactic perigraft arterial sac embolization (pPASE) performed in patients undergoing EVAR. This is a comparison of two elective cohorts of those undergoing EVAR using the Ovation stent graft with and without prophylactic branch vessel and sac embolization. Patients who underwent pPASE at our institution had data collected in a prospective, IRB approved database. These were compared against the core lab adjudicated data from the Ovation IDE trial. Prophylactic PASE was performed at the time of EVAR with thrombin, contrast and gelfoam if lumbar or mesenteric arteries were patent. Endpoints included freedom from ELII, reintervention, sac growth, all-cause mortality (ACM) and aneurysm-related mortality (ARM). Thirty-six patients (13.1%) underwent pPASE, while 238 patients (86.9%) had standard EVAR. Median follow-up was 56 months (IQR 33-60). The 4-year freedom from ELII estimates were 84% for the pPASE vs 50.7% for the standard EVAR group (P=0.0002). All aneurysms in the pPASE group remained stable in size or demonstrated regression, whereas aneurysm sac expansion was seen in 10.9% of the standard EVAR group, P=0.03. At 4 years, mean AAA diameter decreased by 11mm (95% CI 8-15) in the pPASE group vs 5mm (95%CI 4-6) for the standard EVAR group, P=0.0005. There were no differences in the 4-year freedom from ACM and ARM. However, the difference in reintervention for ELII trended toward significance (0.0% vs 10.7%, P=0.1). On multivariable analysis, pPASE was associated with a 76% reduction in ELII [aHR(95%CI): 0.24 (0.08-0.65), P=0.005]. These results suggest that pPASE in those undergoing EVAR is safe and effective in the prevention of EII and significantly improves sac regression over standard EVAR while minimizing the need for reintervention.

Outcomes of Endovascular Aneurysm Repair with Adjunctive Stenting

Endovascular aneurysm repair is the standard of care for abdominal aortic aneurysm repair, however data regarding adjunctive stenting at the time of endovascular aneurysm repair (EVAR) are limited. The study aims to evaluate outcomes of patients undergoing EVAR with and without adjunctive stenting. Patients undergoing EVAR with stenting (EVAR-S) and without stenting (EVAR) (2008 - 2017) were selected from Cerner HealthFacts database using ICD-9 diagnosis and procedure codes. Chi-square analysis and multivariable logistic regression were used to evaluate the association of patient characteristics with medical and vascular outcomes. 4,957 patients undergoing EVAR procedures were identified (3,816 EVAR and 1,141 EVAR-S). Demographic analysis revealed that patients who underwent EVAR-S had higher Charlson comorbidity scores (2.35 vs. 2.13, P=0.0001). EVAR-S was associated with a greater frequency of vascular complications such as thrombolysis/percutaneous thrombectomy (0.9% vs. 0.2%; P < 0.0004). There were no differences seen in access complications between EVAR and EVAR-S. Multivariable analysis revealed that EVAR-S was associated with prolonged length of stay (OR 1.37, 95% CI 1.03-1.82), readmission < 30 days (OR 1.36, 95% CI 1.11-1.68), major adverse cardiac events (OR 1.59, 95% CI 1.09-2.32), respiratory complications (OR 1.47, 95% CI 1.16-1.88) and renal failure (OR 1.57, 95% CI 1.16-2.11). Endovascular aneurysm repair with adjunctive stenting (EVAR-S) was associated with vascular complications requiring reintervention, although the overall rate was very low. As well, readmission within 30 days, cardiac complications, respiratory problems and renal failure were more likely when compared to standard EVAR. The need for adjunctive stenting acts as a marker for an overall sicker and more complex population, not just in terms of vascular complications but across all medical complications as well. Staging the procedure may be helpful in terms of spreading out the operative risk into smaller portions. Furthermore, consideration of a non-operative strategy should be discussed with the patient if the risk of the procedure outweighs the risk of aneurysm rupture in high-risk groups.

The fate of endoleaks after endovascular aneurysm repair and the impact of oral anticoagulation on their persistence

BackgroundThe impact of anticoagulation on late endoleaks after endovascular aneurysm repair (EVAR) is unclear despite multiple investigators studying the relationship. The purpose of this study was to determine if long-term anticoagulation impacted the development of late endoleaks and if specific anticoagulants were more likely to exacerbate the development of endoleaks. MethodsUsing the Society for Vascular Surgery Vascular Quality Initiative database, patients undergoing EVAR between 2003 and 2019 for abdominal aortic aneurysms were evaluated. Patients were divided into two groups: those without a late endoleak and those with a late endoleak. Bivariate analysis was performed to assess preoperative, intraoperative, postoperative, and long-term follow-up variables. A multivariable analysis was done to determine associations of independent variables with late endoleaks. Patients were further subcategorized based on anticoagulation status before and after EVAR, specific type of anticoagulation, and the presence of an index endoleaks (diagnosed at the time of EVAR) to determine the subsequent frequency of late endoleaks. ResultsA total of 29,783 patients were analyzed with 2169 (7.3%) having a late endoleak identified. Several risk factors were related to late endoleaks, including anticoagulation before and after EVAR (odds ratio [OR], 4.23; 95% confidence interval [CI], 2.57-6.96; P < .001), anticoagulation after EVAR (OR, 1.88; 95% CI, 1.43-2.49; P < .001), and index endoleak (OR, 1.45; 95% CI, 1.26-1.66; P < .001). The frequency of late endoleaks in patients anticoagulated before and after EVAR and after EVAR as compared with those never anticoagulated was 16.89% and 14.40% vs 6.95%, respectively (both P > .001). No difference in late endoleaks were noted for patients treated with warfarin and novel oral anticoagulants. The most common type of index and late endoleak identified was type II, but patients with type I, type II, and type IV index endoleaks were more commonly found to have type I, type II, and type IV late endoleaks, respectively. The frequency of late endoleaks in patients with both an index endoleak and anticoagulation after EVAR was 20.42% as compared with patients with only anticoagulation after EVAR (14.63%; P = .0015) and with patients with index endoleaks not anticoagulated (10.06%; P < .00001). ConclusionsLate endoleaks were more common in patients treated with anticoagulation after EVAR. No difference in late endoleak frequency was detected between anticoagulation with warfarin and novel oral anticoagulants. Patients on anticoagulation and those with an index endoleak were at a higher risk of having a late endoleak.

Prophylactic Aneurysm Embolization during EVAR Is Safe, Improves Sac Regression and Decreases the Incidence of Type II Endoleak

Clinically significant endoleaks remain costly, time-consuming, morbid and even mortal following endovascular aneurysm repair (EVAR). Perigraft arterial sac embolization (PASE) has been utilized to treat type II endoleaks (T2EL) diagnosed at the time of EVAR or after repair. Our objective was to analyze the safety and efficacy of prophylactic PASE on the incidence of T2EL and aneurysm sac regression in patients undergoing EVAR. We performed a retrospective review of prospectively maintained databases from the University of California San Diego and the San Diego Veterans Affairs hospitals between 2015 and 2019. Prophylactic PASE (pPASE) was performed at the time of EVAR with thrombin, contrast and gelfoam liquid embolic aneurysm treatment as previously described. We evaluated technical success, freedom from T2EL, freedom from reintervention, from sac expansion, from type I/III EL, from all-cause mortality (ACM), from aneurysm-related mortality and from non-target embolization (NTE). A total of 44 patients were included in the study. Technical success was 100% and no NTE was observed. The average duration of follow-up was 14±11months. In those treated and followed by CT scan, 100% of patients' aneurysms halted their growth following PASE, while 65.9% demonstrated sac regression. Mean aneurysm sac diameter decreased by 9mm (95% CI 7-12). At 3 years, freedom from T2EL was 87.1%. Presence of T2EL did not result in aneurysm expansion during the follow-up period and thus did not require reintervention in any of these patients. Freedom from re-intervention was 83.2% for Type Ib EL and limb occlusion and all procedures were determined to be successful at the time of completion. No aneurysm-related deaths occurred during the follow-up. PASE proves to be an effective tool in sac management for prophylaxis of endoleak and maximizing sac regression in EVAR. It is safe, effective and durable when employed in this manner in the short and medium-term and was associated with low rates of T2ELs and reinterventions and a 100% freedom from sac expansion. Further analysis is required to evaluate the long-term outcomes of this adjunctive procedure in EVAR.

Midterm evaluation of perigraft arterial sac embolization in endovascular aneurysm repair

ObjectiveManagement of clinically significant endoleaks (ELs) remains costly, time-consuming, and morbid. Unresolved ELs can result in rupture and mortality after endovascular aneurysm repair (EVAR). Perigraft arterial sac embolization (PASE) has been used to treat ELs diagnosed at the time of EVAR or during surveillance. MethodsA retrospective review of prospectively maintained databases was conducted. The databases were compiled from two institutions between 2006 and 2016. PASE was performed for type I, type II, or type III EL with a thrombin, contrast medium, and Gelfoam (Pfizer, New York, NY) slurry prepared as previously described. PASE was administered either at the time of EVAR (primary) or during surveillance (secondary). Safety end points included nontarget embolization, defined as neurologic or enteric clinical sequelae from lumbar artery or visceral artery embolization, allergic reaction, peripheral embolization, or rupture. Efficacy end points included successful resolution of EL and cessation of aneurysm sac growth on computed tomography (CT) scans with contrast enhancement. ResultsA total of 66 patients included in the study were treated with PASE. Primary PASE was performed in 38 patients (58%) and secondary in 28 (42%). Within the total cohort, the average clinical and CT scan follow-up was 1.7 years (0.1-11.6 years). Four patients required open repair for residual high-pressure ELs (one type IIIB and three type I; 6%). Of the 95% of patients who did not require open conversion, aneurysm growth did not occur during the follow-up period. In the overall cohort, PASE was successful in 88% of type I EL and 73% of patients with type II EL. There was no evidence of recanalization after thrombosis of culprit vessel for EL. No patients suffered nontarget embolization, spinal ischemia, allergic reaction, post-EVAR rupture, or colonic ischemia. ConclusionsPrimary and secondary PASE proved to be a safe, effective, and durable tool in sac management in conjunction with EVAR. Treating ELs during or after EVAR with PASE has minimized the incidence of EL on CT scan and halted aneurysm growth in our cohort. Further studies are needed to confirm the long-term durability of PASE in reducing secondary interventions after EVAR.

Strategy to avoid open surgical conversion after endovascular aortic aneurysm repair for patients with infrarenal abdominal aortic aneurysm.

PurposeOpen surgical conversion (OSC) is the last treatment option for patients with endovascular aneurysm repair (EVAR)failure. We investigated the underlying causes of EVAR failure requiring OSC and attempted to determine strategies to avoid OSC after EVAR.MethodsWe retrospectively reviewed the database of patients who underwent OSC after EVAR from 2005 to 2018 in a single institution. Twenty-six OSCs were performed in 24 patients (median age, 74.5 years; 79.2% of males) who had undergone standard EVAR. We investigated pre-, intra-, and postoperative computed tomography or angiographic images and outcomes of the OSCs.ResultsTwo main indications for OSC were persistent endoleak (50.0%) and endograft infection (EI) (38.5%). All 13 patients who underwent OSC due to endoleaks received EVAR outside of indications for use. Among 10 patients who underwent OSC due to EI, we found overlooked infection sources in 7 (70.0%) at the time of EVAR or during the surveillance period. OSC was performed at a median of 31.8 months (interquartile range, 9.4–69.8) after EVAR as an emergency (15.4%) or elective (84.6%) surgery. Aortic endograft was removed in 84.6% of cases (totally, 57.7%; partially, 26.9%), whereas it was preserved in 4 cases (15.4%). After 26 OSCs, 2 early deaths (7.7%) and 2 aortoenteric fistulae (7.7%) developed as major complications.ConclusionOSC after EVAR was associated with relatively higher perioperative morbidity and mortality. To avoid OSC after EVAR, we recommend careful assessment of coexisting infection sources and avoidance of EVAR for patients with especially unfavorable anatomy for EVAR, particularly the in proximal neck.

Correlation of Baseline Plasma and Inguinal Connective Tissue Metalloproteinases and Their Inhibitors With Late High-Pressure Endoleak After Endovascular Aneurysm Repair: Long-term Results

Purpose: To investigate whether plasma and connective tissue matrix metalloproteinases (MMP) and their inhibitors (TIMP) may predict late high-pressure endoleak after endovascular aneurysm repair (EVAR). Materials and Methods: Samples of inguinal fascia and blood were collected in 72 consecutive patients (mean age 73.1 years; 68 men) undergoing primary EVAR with the Endurant stent-graft. Baseline plasma levels of MMP-2, MMP-9, TIMP-1, and TIMP-2 and baseline MMP-2 and MMP-9 activity estimated using gelatin zymography (GZ) were compared between patients who developed late endoleak in follow-up and those who did not. Subgroup analyses were performed between patients with (n=18) and without inguinal hernias and between patients with moderate-diameter (50–59 mm; n=45) or large-diameter (≥60 mm; n=27) abdominal aortic aneurysms (AAA) at primary EVAR. Results: The mean follow-up period was 63.1 months (range 7.5–91.5), during which time 13 (18.1%) patients developed type I (6 Ia and 5 Ib) or 2 type III endoleaks. Only GZ-analyzed proMMP-9 concentrations were higher in the endoleak group than in patients without endoleak (mean difference 8.44, 95% CI −19.653 to −1.087, p=0.03). The patients with primary inguinal hernia at presentation had significantly higher tissue TIMP-2 values (0.8±0.7 vs 0.5±0.4, p=0.018) but lower plasma total (pro- + active) MMP-9 values (11.9±7.8 vs 16.2±7.4, p=0.042) than patients without hernias at the time of EVAR. Patients with AAAs ≥60 mm had significantly higher mean tissue homogenate levels of total (pro- + active) MMP-9 (p=0.025) and total (pro- + active) MMP-2 (p=0.049) as well as higher proMMP-9 (p=0.018) and total (pro- + active) MMP-9 (p=0.021) levels based on GZ compared to patients with moderate-diameter AAAs. Regression analysis revealed a significant association between total (pro- + active) MMP-9 plasma samples and the presence of hernia (OR 0.899, 95% CI 0.817 to 0.989, p=0.029) and between GZ-analyzed proMMP-9 and late endoleak (OR 1.055, 95% CI 1.007 to 1.106, p=0.025). GZ-analyzed proMMP-9 and active MMP-9 were strong predictors of late endoleak in patients with hernia (p=0.012 and p=0.044, respectively) and in patients with AAAs ≥60 mm (p=0.018 and p=0.041 respectively). Conclusion: Inguinal fascial tissue proMMP-9 significantly predicted late endoleak. ProMMP-9 and active MMP-9 biomarkers are significantly associated with late endoleak in hernia patients and in patients with AAAs ≥60 mm. Considering the clinical association between hernia and AAA and the fact that the AAA wall connective tissue environment remains exposed to systemic circulation after EVAR, inguinal fascia extracellular matrix dysregulation and altered MMP activity may reflect similar changes in AAA biology, leading to complications such as endoleak.

PC030. Endovascular Aneurysm Repair Graft Explantation Should Not Be Delayed Until Symptoms or Rupture Occurs: A Canadian Multicenter Experience

Most of the literature describing endovascular aneurysm repair (EVAR) explantations has been from single, high-volume centers. We carried out a multicenter cross-Canadian study of outcomes after EVAR graft explantations. Our objectives were to describe outcomes after late open conversion and explantation of EVARs from various Canadian centers and to identify predictors of mortality. The Canadian Vascular Surgery Research Group carried out a retrospective multicenter study of all cases of EVAR graft explantation occurring at participating centers between 2003 and 2018. Data were collected using a standardized, secure, online platform (REDCap). Univariate statistics were used to examine variables associated with mortality. Patients' data from 99 EVAR explantations collected from 13 participating centers were analyzed. Mean age at the time of explantation was 74 years and average aneurysm size was 7.4 cm, with 27% having at least one violation of the instructions for use at the time of EVAR. Average time between EVAR and explantation was 43 months. The most common indications for explantation were type IA endoleak in 44 cases, graft infection in 19 cases, endotension in 11 cases, type II endoleak in 8 cases, type III endoleak in 4 cases, type IV endoleak in 3 cases, graft thrombosis in 4 cases, and others in the remaining 6 cases. Explantations occurred electively in 58 cases, urgently for symptoms in 22 cases, and for rupture in 17 cases. Overall 30-day mortality was 12%, and 50% of patients suffered at least one major perioperative complication. Mortality was significantly higher for ruptured patients (35%) and symptomatic patients (12.5%) compared with elective patients (5%; P = .004). Mortality was higher after explantation for graft infection (21%) compared with endoleak (10%), but this did not reach significance (P = .21). Average center volume during the last 15 years was 8 cases with a wide range of 2 to 19 cases. Mortality in centers with fewer than eight cases was higher than in those with eight or more cases (21.4% vs 8.5%), but again, this did not reach significance (P = .08). The yearly incidence of EVAR explantation increased significantly during the study period (Fig). EVAR graft explantations have an increasing incidence in Canada. Patients having elective explantation have a lower mortality, and thus patients who have an indication should be offered surgery before symptoms or rupture occurs. There is a trend toward higher mortality when explantation is done for infection and in centers with lower volumes.

FT08. Retrospective Review of Underlying Causes of Endovascular Aneurysm Repair Failure Requiring Open Conversion

Most endovascular aneurysm repair (EVAR) complications can be treated by endovascular means. However, some patients require open conversion (OC) after EVAR because of complications that are resistant to endovascular treatment. The frequency of OC after EVAR has been variously reported because of different follow-up duration and diagnostic program of the EVAR complications. Surgical morbidity and mortality associated with OC were reported to be significantly higher compared with the standard open surgical repair of abdominal aortic aneurysm. We attempted to search for underlying causes of EVAR failure requiring OC. OC was defined as surgical opening of the aneurysmal sac after EVAR regardless of aortic cross-clamping or stent graft removal. To find underlying causes of EVAR failure requiring OC, we retrospectively reviewed history of infection after EVAR, endovascular reintervention after EVAR, pre- and post-EVAR computed tomography images, and angiographic images during the EVAR procedure. Diagnosis and type of endoleak depended on computed tomography, ultrasound, and operative findings. For the diagnosis of endograft infection (EGI), we followed the Management of Aortic Graft Infection Collaboration (MAGIC) criteria (EJVES 2016;52:758-63). Twenty-three OCs (institutional, n = 8) were performed for 22 patients (median age, 75 years; male, 83%) at a mean 26 months (2-130 months) after EVAR during the past 14 years. Our institutional frequency of OC was 1.8% after standard EVAR. Indications for OC were end leak (n = 11 [48%]), EGI (n = 9 [39%]), aortic rupture (n = 4 [17%]; 1 intraoperative and 3 late ruptures), and continuous sac enlargement without evidence of endoleak (n = 2 [9%]). Endoleaks requiring OC were type IA (n = 5), type IB (n = 1), type IIIA (n = 1), and type IIIB (n = 2). Among nine EGIs, three (33%) patients presented with aortoenteric fistula or erosion. Among the patients with EGI, the infection source was identifiable in four (44%) patients, which included EVAR for patients with infected abdominal aortic aneurysm (n = 2) and coexisting psoas abscess at the time of EVAR (n = 2). Among five late EGIs, three patients showed a remote site infection source, including leg cellulitis, gingival abscess, and bacteremia. Among four aortic ruptures, one patient required OC because of intraoperative aortic rupture during EVAR. As a result of OC, we have experienced one (4%) surgical death and three early postoperative complications, including late midcolic artery rupture in type I neurofibromatosis, left colon ischemia, and acute renal insufficiency. We think that at least 73% of OCs due to endoleak, 44% of OCs due to EGI, and 25% of aortic ruptures are preventable by proper selection of EVAR candidates and careful endovascular technique.

Characterization and outcomes of reinterventions in Food and Drug Administration-approved versus trial endovascular aneurysm repair devices

ObjectivePublished rates of reintervention after endovascular aneurysm repair (EVAR) range from 10% to 30%. We evaluated a single university center's experience with reinterventions in the context of Food and Drug Administration (FDA)-approved and trial devices. MethodsRetrospective data collection was performed for patients who underwent infrarenal EVAR and required reintervention from 2000 to 2016. Trial devices included those used in FDA feasibility and pivotal trials. Time-to-event analysis was performed using Cox regression. Predictors of mortality and explantation were evaluated using logistic regression; survival analysis was performed using Kaplan-Meier methods. ResultsFrom 2000 to 2016, there were 1835 EVARs performed, and 137 patients (116 men; mean age, 72.2 ± 10.0 years) underwent reintervention with a mean aneurysm size of 5.9 ± 1.2 cm. The median follow-up was 5 years with an overall survival of 70.1%. The overall reintervention rate was 7.5%. FDA-approved devices had a reintervention rate of 6.4%, whereas trial devices had a rate of 14.4% (P < .001). For all devices, the most common cause of reintervention was type II endoleak (52.5%), followed by type I endoleak (18.2%), type III endoleak (9.5%), limb kink (7.3%), iliac occlusive disease (5.8%), endotension (1.5%), and other. The overall mean time to first reintervention was 2.3 ± 2.5 years, and univariate Cox regression identified male gender (hazard ratio, 1.91; 95% confidence interval [CI], 1.17-3.10; P = .010) and age at the time of EVAR (hazard ratio, 1.03; 95% CI, 1.01-1.05; P = .006) as risk factors for time to first reintervention. Among patients requiring reintervention, the mean number of reinterventions for trial devices was significantly greater than that for FDA-approved devices (2.18 vs 1.65; P = .01). Trial devices requiring reintervention had a nearly threefold higher odds for the need for more than two reinterventions (odds ratio, 2.88; 95% CI, 1.12-7.37; P = .034). Trial device, cause of reintervention, and type of reintervention were not predictive of the need for explantation or mortality, but the number of reinterventions was significantly associated with the need for explantation (odds ratio, 1.86; 95% CI, 1.17-2.96; P = .012). EVAR device and the need for explantation did not have an impact on mortality. ConclusionsDespite the rigorous nature of patient enrollment in clinical trials and the development of newer iterations of investigational devices, patients undergoing EVAR with trial devices are more likely to undergo a greater number of reinterventions than with FDA-approved devices. Although mortality and the need for explantation were not significantly associated with trial devices, the finding of a greater number of reinterventions highlights the need to properly inform patients willing to partake in investigational device trials.

Prophylactic accessory renal artery coil embolization for prevention of type II endoleak following endovascular aneurysm repair: a case report

BackgroundPrior reports indicate that intentional coverage of the accessory renal arteries (ARAs) with a diameter larger than 3 mm during endovascular aneurysm repair (EVAR) increases risk of additional treatment for type II endoleak. Here, we report a case of prophylactic coil embolization for a 4 mm ARA originating from an abdominal aortic aneurysm.Case presentationA 76-year-old woman was admitted to our hospital after noticing an abdominal pulsatile mass. Computed tomography (CT) imaging revealed an abdominal aortic aneurysm (AAA) with a maximum diameter of 53 mm. Preoperative CT scan showed a right ARA, 4 mm in diameter, which was considered likely to lead to type II endoleak following EVAR. ARA coil embolization was performed at the time of EVAR. We observed no endoleaks and no infarct of the inferior pole of the right kidney on completion angiography. The postoperative course was uneventful, and the patient was discharged 7 days later. Postoperative eGFR (58.4 ml/min) was not significantly different from preoperative level (56.7 ml/min). After EVAR, blood pressure was under control, and no additional anti-hypertensive medicines were required. Postoperative enhanced CT image showed that the distal portion of the ARA was well perfused without type II endoleak from ARA.ConclusionsProphylactic coil embolization for a large ARA originating from an abdominal aortic aneurysm appears to be safe and effective in preventing type II endoleak following EVAR.

The impact of concomitant procedures during endovascular abdominal aortic aneurysm repair on perioperative outcomes

Concomitant procedures during endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm are performed to facilitate endograft delivery, to simultaneously treat unrelated conditions, or to resolve intraoperative pitfalls. The frequency and perioperative impact of these procedures are not well described. This study aimed to assess the frequency and perioperative impact of various concomitant procedures performed at the time of EVAR. We included all elective EVARs in the Vascular Study Group of New England between January 2003 and November 2014 and identified those with and those without concomitant procedures. Multivariable logistic regression analysis was used to establish the independent association between concomitant procedures and perioperative outcomes. The study included 4033 patients, with 1168 (29.0%) patients undergoing one or more additional procedures. Independent risk factors for 30-day mortality were concomitant femoral endarterectomy (odds ratio [OR], 4.8; 95% confidence interval [CI], 2.1-11.2) and renal angioplasty or stenting (OR, 3.1; 95% CI, 1.2-8.3). Postoperative bowel ischemia was associated with hypogastric embolization (OR, 3.8; 95% CI, 1.1-13.4) and iliac angioplasty or stenting (OR, 3.5; 95% CI, 1.3-9.6). Leg ischemia was associated with unplanned graft extension (OR, 2.3; 95% CI, 1.02-5.0), other artery reconstruction (OR, 5.2; 95% CI, 1.8-15.1), thromboembolectomy (OR, 5.2; 95% CI, 1.3-20.8), and repair of arterial injury (OR, 4.6; 95% CI, 1.2-18.3). Risk factors for deterioration of renal function were iliofemoral bypass (OR, 3.9; 95% CI, 1.3-12.2), other artery reconstruction (OR, 2.7; 95% CI, 1.3-5.8), renal angioplasty or stenting (OR, 2.5; 95% CI, 1.3-4.6), and repair of arterial injury (OR, 4.5; 95% CI, 1.6-12.2). Myocardial infarction was associated with femorofemoral bypass (OR, 3.9; 95% CI, 1.7-8.7), other artery reconstruction (OR, 3.9; 95% CI, 1.6-9.2), and repair of arterial injury (OR, 6.1; 95% CI, 1.8-21.0). Wound complications were predicted by femorofemoral bypass (OR, 13.4; 95% CI, 5.8-31.1). Concomitant procedures during EVAR are associated with increased postoperative morbidity and mortality. The need for performing concomitant procedures should be carefully considered. The morbidity associated with intraoperative complications highlights the importance of avoidance of arterial injury and thromboembolic events where possible.

What Factors Predict Wound Complications after Endovascular Aortic Aneurysm Repair?

s Accepted for Presentation during the 2015 Southern California Vascular Surgical Society Annual Meeting Endoleak after Modular Bifurcated Stent Versus Unibody Stent Graft for Endovascular Treatment of Infrarenal Abdominal Aortic Aneurysm Neha Sheng, Phong Dargon, Jason T. Chiriano, Theodore H. Teruya, Sheela T. Patel, Ahmed M. Abou-Zamzam Jr., and Christian Bianchi Loma Linda, California. Background: The purpose of our study is to report on results of endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA) and postoperative aneurysm sac diameter change, after repair with modular bifurcated and unibody aortic stent grafts. Methods: We retrospectively reviewed a prospectively maintained database of all endovascular aneurysm repair (EVAR) procedures performed for infrarenal abdominal aortic aneurysms (AAA) at a single VA institution. A total of 113 patients underwent EVAR for infrarenal AAA between October, 2008 and November, 2011. Patients were included if they underwent elective EVAR for asymptomatic infrarenal AAA greater than 5 centimeters in diameter, and if preoperative and postoperative imaging was available for review. Patients were assessed with clinical examination and CT scan at 1, 6, and 12 months and yearly thereafter. Results: Fifty patients underwent EVAR with a modular bifurcated graft: Gore Excluder (n 41, 82%), Medtronic Talent (n8, 16%), Cook Zenith (n1, 2%). Sixty-three patients underwent EVAR with the Endologix unibody design stent graft. Thirty-six patients (72%) in the modular bifurcated group met the criteria for the instructions for use (IFU) of the graft inserted (Mod-IFU), and 14 patients (28%) did not (Mod-non IFU). Fifty-two patients (83%) in the unibody group met the IFU criteria (Uni-IFU), and 11 (17%) did not (Uni-nonIFU). Overall follow-up was 20.1 months. Rate of postoperative endoleak was 27.8% in the Mod-IFU group, 28.6% in the Mod-non IFU group, and in 27.3% in the Uni-non IFU group, and 7.7% in the Uni-IFU group. Conclusions: Overall, fewer endoleaks are noted in patients meeting IFU criteria and undergoing EVAR for infrarenal AAA with unibody stent graft design. http://dx.doi.org/10.1016/j.avsg.2015.03.002 870 What Factors Predict Wound Complications after Endovascular Aortic Aneurysm Repair? Michael F. Amendola, Luke Wolfe, Marcella WoogenFisher and John Pfeifer Hunter Holmes McGuire VA Medical Center, Richmond, VA. Introduction: Endovascular aortic aneurysm repair (EVAR) is becoming thepreferredmethod for treating infrarenal aortic aneurysms. The majority of EVAR procedures require a groin incision to access the common femoral artery. Weset forth to examineourEVARpopulation to discover factors that contribute to wound complications post-operatively. Methods: With Institutional Board Review approval, we retrospectively queried our Veterans Administration Hospital operative database to identify male patients who underwent EVAR from January 1, 2010 to December 31, 2012. Each patient’s groin wound was considered individually and no adjunctive procedures were performed at the time of EVAR. All re-operative groins were excluded. Patients were followed for wound infection, wound breakdown, wound revision, and lymphatic leaks. Patients with wound complications (WC) were compared to patients with no wound complication (NWC). Age, body mass index (BMI), operative times, and CT calculated wound depth (CWD) were recorded. CWD was defined as the perpendicular distance measured in centimeters from the common femoral artery just proximal to the profunda femoris artery to the nearest skin edge. Receiver operator correlations were calculated for BMI as compared to CWD. Age, history of hypertension, history of diabetes, pre-EVAR hypogastric intervention, side of wound, incision type (vertical or horizontal) and operative times were also collected. Results: A total of 142 incisions were followed in 71 male patients. There was a 14.8% total wound complication rate. The WC group had a statistically higher BMI and CWD. Age, operative times, history of hypertension, history of diabetes, pre-EVAR hypogastric intervention, side of wound, incision type (vertical or horizontal), operative times, history of smoking and death rates were not statistically different between the two groups. Spearman Correlation Coefficient of 0.80300 (p 50, history of CHF, paraplegia, prior operation in last 30 days, emergent surgery, unplanned reintubation, and septic shock were independently associated with increased 30-day mortality. (table 2). Conclusion: Overall 30-day mortality was not significantly different between the two surgical techniques. However, older patients with more medical comorbidities underwent TEVAR. Age >50, history of CHF, operation in the previous 30 days, emergency surgery, unplanned re-intubation, and septic shock were independent predictors of 30-day mortality. http://dx.doi.org/10.1016/j.avsg.2015.03.004 Endovascular Repair of Mycotic Aneurysms e An Evolving Paradigm Erin Ward, Erik Owens, John Lane and

Risk Factors on Acute Kidney Injury After Endovascular Aortic Aneurysm Repair

The aim of this study was to evaluate the estimated glomerular filtration rate (eGFR) using the most contemporary formula with perioperative endovascular aneurysm repair (EVAR) patients and to examine the risk factors of acute kidney injury. The 382 consecutive patients who underwent EVAR from June 2007 to September 2013 were retrospectively examined. Excluded were 10 patients with end-stage renal disease receiving hemodialysis, 6 patients with a history of aneurysm repair using fenestrated or branched devices, 1 patient in whom nephrectomy was performed at the same time of EVAR, and 1 patient with a ruptured aneurysm. eGFR was determined by using the Japanese equation modified by the Japanese Society of Nephrology in 2009. The patients were divided into five groups based on chronic kidney disease (CKD) classification, namely, G1: eGFR ≥90 mL/min/1.73 m2, G2: 60≤eGFR <90, G3a: 45≤eGFR < 60, G3b: 30≤eGFR <45, and G4: eGFR <30. AKI was defined as a decrease in eGFR >25% of the baseline within 7 days after EVAR. In patients with G3b and G4, pretreatments, including intravenous hydration with normal saline, were routinely performed. A total 364 patients (mean age, 77.9 ± 6.4 years) were included. The number of patients in each group was 22 in G1, 149 in G2, 117 in G3a, 58 in G3b, and 17 in G4. AKI occurred in 28 patients (7.7%), and these patients were labeled the AKI group, while the remaining 336 patients who did not suffer from AKI (92.3%) comprised the non-AKI group. The median dose of contrast agent (113 mL [70, 65-245] for the AKI group vs 100 mL [54, 8-330]; P = .04 for the non-AKI group) and the duration of the operating time (196 minutes [121, 84-484] for the AKI group vs 141 minutes [53, 66-390]; P < .0001 the non-AKI group) were significantly different between two groups. However, the age, preoperative eGFR, anesthesia type, fixation type of devices, and blood loss during the procedure were not significantly different between the groups. AKI was 0% in G1, 6.7% (n = 10) in G2, 11.1% (n = 13) in G3a, 8.7% (n = 5) in G3b, and 0% in G4. One female patient in G3a received hemodialysis during hospitalization. The mean amount of contrast medium used was 99 mL in G1 (37.5, 40-200), 100 mL in G2 (57.5, 45-330), 105 mL in G3a (55, 45-260), 90 mL in G3b (70, 24-250), and 45 mL in G4 (69.5, 8-160). The amount of the contrast medium in G4 patients was significantly smaller than that of the other four groups. The risk of AKI in elderly CKD patients after EVAR of AAA is similar to that of non-CKD patients. Long operation time is a AKI strong risk factor. It is suggested that EVAR is feasible in elderly CKD patients with careful attention paid to reducing the amount of the contrast and renal protection using hydration treatment or intravascular ultrasound during the operation. Our study may contribute to expanding EVAR treatment in elderly CKD patients.

Statin therapy is associated with aneurysm sac regression after endovascular aortic repair

Several anatomic factors have been identified as predictive of sac behavior after endovascular aneurysm repair (EVAR). The effects of statin therapy on aneurysm sac size reduction remain controversial. This study tested the hypothesis that statin therapy enhances aneurysmal sac regression after EVAR. This monocentric retrospective study included patients with abdominal aortic aneurysms treated by EVAR using the Zenith (Cook, Bloomington, Ind) graft device. We excluded patients presenting with perioperative sac enlargement factors such as endoleaks, endotension, infectious, inflammatory, ruptured, or anastomotic aneurysms. We prospectively assessed standard clinical and anatomic data, as well as statin use, at the time of EVAR and during follow-up. The primary end point was the decrease in the largest transverse aortic diameter at 24 months compared with the preoperative diameter. Among 166 patients treated by a Zenith device and meeting the inclusion criteria, 120 were identified as statin users and 46 as nonstatin users, with comparable characteristics. At 24 months of follow-up, statin group patients had a greater aneurysm sac reduction (25% vs 14%; P < .0001). At a threshold of 5 mm in diameter regression, statin use was a positive factor of retraction (odds ratio, 7.93; 95% confidence interval, 3.22-15.52; P < .0001). Multivariate analysis revealed statin use was an independent predictive factor of sac regression (adjusted odds ratio, 9.39; 95% confidence interval, 3.45-25.56). This study showed that statin use was predictive of sac regression after EVAR with the Zenith graft device. This effect needs to be confirmed by larger randomized trials or by large population evaluation.

Femoral-femoral stabilizing buddy wire for embolization of the internal iliac artery

Internal iliac artery (IIA) embolization is performed in a variety of clinical scenarios, most commonly in patients undergoing endovascular aneurysm repair (EVAR) with an iliac artery aneurysm or inadequate distal landing zone. In these patients, IIA embolization with iliac limb extension is often performed. While IIA embolization can be routinely performed with either ipsilateral or contralateral femoral arterial access, it can be challenging in some patients with an acutely angulated aortic or iliac bifurcation and in patients with short or ectatic common iliac arteries. In this select group of patients with difficult anatomy, IIA embolization can be challenging and may lead to increased radiation exposure and contrast administration. Having a sheath precisely positioned and stabilized at the internal iliac artery origin will facilitate embolization of the IIA. This report describes a novel technique in which crossover femoral-femoral artery buddy wire placement achieves stable positioning of large sheaths for concurrent IIA embolization at the time of EVAR.

The effect of warfarin therapy on endoleak development after endovascular aneurysm repair (EVAR) of the abdominal aorta

The presence of an endoleak after endovascular abdominal aortic aneurysm (AAA) repair (EVAR) may predispose to sac expansion and potential sac rupture. The incidence of endoleak after AAA repair can be as high as 20% to 30%. We investigated whether warfarin anticoagulation was an independent risk factor for endoleak after EVAR for AAA. All AAA patients who underwent elective EVAR were prospectively followed-up. Data for demographics, clinical comorbidities, outcomes, EVAR devices, and anticoagulation methods were recorded. All patients underwent routine follow-up at 1, 6, and 12 months and annually thereafter. Computed tomography angiography (CTA) with 3-dimensional (3D) volumetric analysis was also completed. During a 7-year period, 127 consecutive patients with infrarenal AAAs who underwent EVAR were monitored for a mean of 2.14 years. The average age at the time of EVAR was 73.8 years. Warfarin therapy alone was administered to 24 patients, and anticoagulation with antiplatelet therapy alone was administered to 103. During the study period, 38 (29.9%) endoleaks were documented. The overall endoleak rate was 13 of 24 in the warfarin group and 25 of 103 in the antiplatelet group (P = .004). CTA 3D volumetric aneurysm sac analysis showed an increase of 16.09% in the warfarin study group and a reduction of 9.71% in the antiplatelet group (P = .04). Anticoagulation with warfarin appears to be linked to an increased risk for the development of endoleak after EVAR, specifically type II. Volumetric analysis showed warfarin therapy also contributed to persistent aneurysm sac expansion. These data suggest that patients who require warfarin anticoagulation for other indications should be advised that they might be at an increased risk for the development of endoleaks, subsequent secondary interventions, persistent sac expansion, and possible delayed sac rupture.

Twelve-year outcomes after endovascular aneurysm repair using earliest available endograft components from a single center

Comprehensive long-term outcome data after endovascular aneurysm repair (EVAR) are scarce, although anecdotes of endograft failure in the early 1990s abound. The objective of this report is to provide comprehensive outcomes after EVAR performed with the earliest available endograft components. These were a home-made endograft (pre-expanded polytetrafluoroethylene [PTFE] fixed with giant Palmaz stents) and first-generation Talent endografts (World Medical, Sunrise, Fla). A prospectively recorded database of all cases undertaken at a tertiary referral center was retrospectively interrogated. Sex, age, types of endograft used, and fate of patient and endografts implanted between 10 and 15 years previously were studied. A literature search was undertaken to obtain data for long-term survival after EVAR and open surgery (OR). There were 50 patients in total operated on between 1994 and 1998 of whom 43 were male. The median age was 73 years (54-93) at time of EVAR and 85 years (67-100) in the survivors at a median of 12 years later. There were 26 home-made (PTFE fixed with Palmaz stents) and 24 Talent endografts (World Medical). Thirty-day mortality was 4%, one death in a ruptured abdominal aortic aneurysm. Twenty-one (42%) survived for 12 years to the time of reporting. Of these, 6 have functioning home-made endografts, 8 have Talent endografts, and 8 (5 home-made and 3 Talent) survive after conversion to OR. Secondary interventions took place in 9 further patients. Of 27 late deaths, 1 suffered endograft sepsis, 20 died of cardio-respiratory causes and 6 died of cancer. The only report of more than a 10-year survival after OR was found in an e-publication from Sweden. The projected survival after 10 years was 40% for unruptured aneurysms. However, survival in the general population was higher at 60%. Ten-year survival after EVAR parallels that of elective OR but is less than the general population. Although the rate of eventual conversion to open repair was high using this earliest available endograft technology, the aneurysm-related mortality was low, and both endografts remain functional for more than 10 years after placement.

Intraoperative Intrasac Thrombin Injection to Prevent Type II Endoleak after Endovascular Abdominal Aortic Aneurysm Repair

To report a prospective, nonrandomized pilot study to determine whether fibrin glue aneurysm sac embolization at the time of endovascular aneurysm repair (EVAR) is a safe and effective procedure to primarily prevent type II endoleaks. Between June 2003 and December 2005, 84 consecutive patients (79 men; mean age 73.8+/-7.8 years, range 64-86) with degenerative infrarenal abdominal aortic aneurysm underwent EVAR with bifurcated stent-grafts and fibrin glue injection into the aneurysm sac at the conclusion of the endovascular procedure. A total of 424 imaging studies and 348 visits were recorded during the study period and reviewed. Selective catheterization of the aneurysm sac and fibrin glue injection immediately after initial stent-graft deployment was successful in 83 (99%) of 84 cases; there was one failure to access the excluded aneurysm sac due to severe iliac artery calcification. The estimated primary and assisted clinical success rates at 2 years were 91.3% and 98.8%, respectively, but the major findings were the low rate of delayed type II endoleak (2.4%) and the statistically significant decrease in the maximum transverse aneurysm diameter (50.40+/-6.70 versus 42.03+/-6.50 mm, p = 0.0001) at follow-up. In addition, of 31 patients available for 24-month follow-up, 14 (45.2%) patients showed a reduction in maximum transverse aneurysm diameter by >or=5 mm; 16 (51.6%) patients had no significant changes, whereas only 1 patient showed a >5-mm enlargement. This clot engineering approach to aneurysm sac embolization at the time of endografting appears to be safe and may spare the patient a repeated catheter-based intervention or surgical procedure.