Type Ia Endoleak Research Articles

Clinical application of n-butyl-2- cyanoacrylate（NBCA） in the transarterial embolization for type I/II endoleak during and after EVAR surgery

Exploring the effectiveness and safety of n-butyl-2-cyanoacrylate (NBCA) in the transarterial embolization for common endoleak during and after endovascular repair of aortic aneurysm (EVAR). A total of 226 patients with abdominal aortic aneurysm (AAA) were treated with EVAR in 4 years August 2019 to February 2023, including 46 patients with ruptured aneurysms (rAAA). Account 37 cases developed endoleak during EVAR surgery and follow-up period, 28 non-ruptured AAA patients and 9 rAAA patients, then treated with NBCA for transarterial embolization. Follow up for at least six months to observe its clinical efficacy and adverse reactions. Among 37 cases of endoleak, there were eight cases of primary type Ia endoleak and one cases of primary right type Ib endoleak in the rAAA group, one case of primary type Ib endoleak, two cases of secondary type Ia endoleak and 25 cases of Postoperative type II endoleak in the non-ruptured AAA group. Three patients with primary type Ia endoleak were treated with coil assisted NBCA in the rAAA group, while the remaining 34 patients with type I and type II endoleaks were treated with NBCA alone. All transarterial embolization achieved technical success and the endoleak disappeared. Postoperative hospitalization observation showed that three cases patients in the rAAA group who experienced primary type Ia endoleak during emergency EVAR surgery died within 4 days after surgery due to hemorrhagic shock and multiple organ failure. Two patients experienced non-AAA related deaths during the follow-up period. Transartrial embolization with NBCA for the treatment of primary and secondary endoleak is a safe and effective method. It can achieve more dense embolization of the aneurysm sac and more complex endoleaks embolization. And it showed a low recurrence rate of endoleak and the incidence of perioperative complications after surgery, which is worthy of clinical promotion and application. Even in emergency EVAR combined with primary type I endoleak treatment in rAAA patients, patients can still benefit.

Early and Midterm Outcomes of Chimney Endovascular Aortic Repair for Ruptured Abdominal Aortic Aneurysms.

To compare the outcomes of endovascular aortic aneurysm repair using a chimney technique (ch-EVAR) with those of the standard EVAR (st-EVAR) for ruptured abdominal aortic aneurysms (RAAA). We implemented ch-EVAR for juxtarenal RAAA based on obvious anatomical indications after converting the strategy for RAAA from open repair to EVAR. A retrospective, cohort-based study was conducted on patients with RAAA who were treated using EVAR in our hospital between July 2011 and March 2022. EVAR cases were extracted, and outcomes were compared between ch-EVAR and st-EVAR. Patient clinical status, anatomical variables, treatment, and follow-up data were evaluated. A total of 56 (82%) and 12 (18%) patients were treated by st-EVAR and ch-EVAR, respectively. Thirty-day mortality rates were comparable between the 2 groups [8.9% in st-EVAR vs 8.3% in ch-EVAR (p= 0.95)]. Short-term outcomes showed that no type Ia endoleak occurred in either group. Midterm outcomes, including sac enlargement [7.5% in st-EVAR vs 0% in ch-EVAR (p= 0.37)], shrinkage [77.5% in st-EVAR vs 80.0% in ch-EVAR (p= 0.86)], and overall survival and freedom from aneurysm-related reintervention at 3 years [64.7% and 96.4% in the EVAR group vs 91.7% and 100% in the ch-EVAR group, respectively (p= 0.30 and 0.52)], were not significantly different between the 2 groups. Ch-EVAR for RAAA showed remarkably excellent outcomes, comparable to those of st-EVAR. Ch-EVAR is considered technically feasible in experienced centers. The indications for EVAR for RAAA may be further expanded using the chimney technique, resulting in overall improved outcomes for RAAA. This is a retrospective, single-center analysis of 68 patients with ruptured abdominal aortic aneurysms (RAAAs) treated by endovascular repair (EVAR) to investigate the efficacy of the chimney technique for juxtarenal RAAA. Thirty-day mortality rate was 8.3% for the chimney EVAR group, which was equivalent to that in the standard EVAR group. Mid-term outcomes including sac enlargement/shrinkage, overall survival, and freedom from aneurysm-related reintervention were comparable between the two groups. This report suggests the possibility of broadening the selection criteria of the current endovascular strategy using the chimney technique.

LASER FENESTRATION FOR COMPLEX AORTIC REPAIR: VERSATILE OPTION IN DIFFICULT ANATOMY, EMERGENCIES AND BAILOUTS

BackgroundBranched and fenestrated endovascular aortic repair (b/fEVAR) for thoracoabdominal aortic disease as well as thoracic disease (b/fTEVAR) has been well described. Its utilization has also grown over time with the need for solutions having outpaced technologies available in the United States. As more practitioners utilize these and other complex aortic repairs there is a growing utilization of adjunctive modalities expanding the capabilities of current devices. In-situ fenestration (ISF) has arisen as one of those modalities for both vessel fenestration and endoleak repair. ISF has been described for its role in bailout of thoracic endovascular aortic repair (TEVAR) particularly in fenestration for the left subclavian artery, but has not been well described in b/fEVAR in respect to the visceral vessels with most data limited to case series. We sought to review our single institution experience with this technique. MethodsSingle institution retrospective review of ISF during initial b/fEVAR, TEVAR from 2020 to 2022. Laser fenestrations post original b/fEVAR or TEVAR for endoleak repair were also included. Perioperative outcomes were obtained as well as angiographic results and short -term results found on follow up CT scans per SVS guidelines. Detailed operative techniques are discussed. ResultsA total of 13 patients were identified with 17 laser fenestrations. 11 ISF were planned preoperatively and 2 were intra-op decisions. The indications for surgery were type B aortic dissection with malperfusion (3), thoracoabdominal aortic aneurysm (TAAA): Non-ruptured (7), Ruptured (1), Type III endoleak post b/EVAR (1) and Type IA endoleak s/p fEVAR (1). Laser fenestration was used in conjunction of 3 TEVAR and 10 (b/fEVAR). The distribution of vessels fenestrated was: 5 left renal artery (LRA), 5 right renal artery (RRA), 4 left subclavian artery (LSCA), 1 superior mesenteric artery (SMA), 1 Celiac. Technical success was achieved in all 17 fenestrations with no 30-day mortalities, no post op dissection or spinal cord ischemia. There were 3 cases of endoleak at the completion of the operation, 1 type II and 1 type IIIc. ConclusionISF of aortic stent grafts in b/fEVAR and TEVAR is useful as a bailout in complex aortic repair with high likelihood of technical success and low morbidity.

Prediction of late proximal endoleak risk after EVAR by pre-operative estimation of endograft/aortic neck apposition surface

The aim of this study was to evaluate a new measurement tool for the pre-operative computed tomography (CT) scan to estimate the endograft apposition surface on the proximal aortic neck of the aneurysm that would predict the risk of late type IA endoleak (EL1A). From databases of four high-volume centres, between 2004 and 2020 all patients who underwent EVAR with the possibility of analysing pre- and post-EVAR scans and who presented late (>2 years) EL1A in follow-up were included retrospectively (EL1A group). A control group of randomly selected EL1A-free patients were included (control group) and follow-up beyond four years. The measurement tool (Endosize®, Therenva) was used to model a virtual cylinder constrained by the centreline whose diameter was determined from the diameter of the implanted endograft. The apposition surface was calculated by determining the areas of the virtual cylinder mesh outside the mesh of the neighbouring portion of the segmented aorta by an intersection calculation of surface normals. This apposition surface and the usual anatomical data of the proximal neck were compared between the groups with univariate and multivariate analyses. Intra- and inter-observer variability in the measurement of apposition surface was analyzed using the intraclass correlation coefficient (ICC) and the method of Bland and Altman. Sixty-six comparable patients were included, 33 in the EL1A group and 33 in the control group. The mean time to EL1A onset was 50.2 ± 24.6 months in the EL1A group and the mean follow-up time was 79.8 ± 26.8 months in the control group. In univariate analysis, only the endograft apposition surface ratio on the proximal neck was significantly lower in the EL1A group compared with the control group (50.3% vs. 75.5%; p <0.0001). There was no significant difference in classic anatomical neck characteristics. There was no difference in proximal endograft oversizing or in the length from the lowest renal artery to the beginning of the covered portion of the endograft. In multivariate analysis, only the apposition surface ratio was independently correlated with the presence of EL1A (p <0.0001). The estimation of the intra- and inter-observer variability, indicates excellent reliability (ICC = 0.992; ICC = 0.956). The method estimating the pre-operative endograft apposition surface on the proximal aortic neck appears to be a reliable measuring in predicting the risk of occurrence of late EL1A after EVAR.

Physician-Modified Endograft with the TREO Stent Graft System.

Description of physician-modified endograft technique and its advantages using the TREO stent graft system. After partial back-table deployment of the TREO endograft, fenestrations are created using a scalpel and reinforced with a double snare loop and running suture. The distance between the Z-shaped stents of the TREO main body of almost 20 mm allows for more flexible placement of multiple fenestrations and easier and faster re-sheathing. The technique is illustrated with physician modification of a TREO aortic cuff and bifurcated endograft in three patients with juxtarenal aortic aneurysms or type Ia endoleak after previous endovascular aortic aneurysm repair. Physician modification of the TREO stent graft system can be safely performed, making it an excellent additional option to treat juxtarenal aneurysms. The TREO stent graft system offers various sizing options including different main body lengths and diameters, thus increasing applicability. Larger distance between the main body's stents facilitates placement of multiple physician-modified fenestrations. Re-sheathing is easier and faster due to the low number of main body stents which have to be re-sheathed. Therefore, the TREO stent graft system is an excellent platform for the physician-modified technique.

Fenestrated Endovascular Aortic Repair of Complex Aneurysm Using the Anaconda Fenestrated Device: 1-Year Results From the French Multicenter Registry.

This study aims to assess the safety and efficacy of the fenestrated Anaconda device for the treatment of complex aortic aneurysms over 1 year in daily clinical practice. All patients who received the graft between October 2019 and October 2020 were prospectively enrolled in an observational, multicenter national registry. The primary endpoint was the aneurysm-related 1-year mortality rate. Secondary endpoints included all-cause mortality, technical success, device-related adverse events (AEs) and major complications, secondary reinterventions, endoleaks, target vessel (TV) outcomes, and a center-volume analysis comparing mortality and secondary reintervention rate between expert centers (>15 F/BEVAR per year) and nonexpert centers (≤15 F/BEVAR per year). Ninety-seven patients from 28 centers were treated. Aneurysms types included juxta-renal and short neck (84.6%), pararenal (5.2%), paravisceral (3.1%), and type IV thoracoabdominal (2.5%). Configurations with 1, 2, 3, and 4 fenestrations were used in 2, 12, 18, and 65 cases, respectively, totaling 350 TVs. Technical success was 98.0%, with 1 type Ic and 1 type IIIc endoleak. Mean follow-up was 468 days. Ten patients died, with 8 deaths (8.2%) due to non-aortic causes and 2 deaths (2.1%) from unknown causes. The estimated 1-year survival rate was 92.7% (95% CI: 87.8-98.1%). The reintervention rate at 30 days was 11.3% and the estimated reintervention rate at 1 year was 21.6% (95% CI: 12.7-29.6%). No type Ia endoleak occurred during follow-up. Three type III endoleaks occurred and required reintervention. Three TV occlusion occurred, yielding a 1-year TVI-free rate of 92.4% (95% CI: 89.4-99.3). No device-related major complication was recorded, and 3 device-related AEs occurred: 1 limb migration, 1 limb kinking and 1 limb thrombosis. There was no statistically significant difference in mortality and survival without reintervention between expert and nonexpert centers (Log rank p=0.52 and p=0.16, respectively). The fenestrated Anaconda device demonstrated acceptable early and at 1-year safety and efficacy for treating primarily juxta-renal and short-neck aortic aneurysms, in centers with varying levels of experience. The Anaconda Fenestrated, as the second commercially available custom-made device for complex endovascular aortic surgery, might adress some anatomical challenges. Following market authorization, this registry presents the 1-year outcomes of real-world device usage in a large number of centers, including small clinics. The results indicate that the device provided adequate efficacy and safety for treating mostly juxta-renal and short neck aneurysms, with notable improvement in technical success rate compared to older reports.

Endovascular Repair of Ruptured Abdominal Aortic Aneurysms Using the Endurant™ Endograft.

Background: Endovascular aortic aneurysm repair (EVAR) represents a valid treatment modality for ruptured abdominal aortic aneurysms (rAAAs). This study aimed to present rAAA outcomes treated by EVAR using the Endurant endograft. Methods: A single-center retrospective analysis of consecutive patients treated with standard EVAR (sEVAR) or parallel graft (PG)-EVAR for infra- or juxta/para-renal rAAA using the Endurant endograft (1 January 2008-31 December 2023) was undertaken. The primary outcomes were technical success, mortality, and reintervention. Follow-up outcomes, including survival and freedom from reintervention, were assessed using Kaplan-Meier estimates. Results: Eighty-eight patients were included (87.5% sEVAR and 12.5% PG-EVAR). The mean aneurysm diameter was 73.3 ± 19.3 mm (71.4 ± 22.2 mm sEVAR and 81.7 ± 33.0 mm PG-EVAR). Among 77 patients receiving sEVAR, 26 (33.8%) received an aorto-uni-iliac device. All PG-EVAR patients were managed with bifurcated devices, one receiving a single PG, seven double PGS, and three triple PGs. Technical success was 98.8% (100.0% sEVAR and 90.9% PG-EVAR). The 30-day mortality was 47.2% (50.7% sEVAR and 27.3% PG-EVAR), with nine (10.2%) deaths recorded on the table. The mean time of follow-up was 13 ± 9 months. After excluding 30-day deaths, the estimated survival was 75.5% (standard error (SE) 6.9%) at 24 months. The estimated freedom from reintervention was 89.7% (SE 5.7%) at 24 months. Only one endoleak type Ia event was recorded during follow-up. Conclusions: Endurant showed high technical success rates and low rates of endoleak type Ia events and reinterventions, despite the emergent setting of repair. rAAA is still a highly fatal condition within 30 days, with an acceptable mid-term survival of 30-day survivors at 75.5%.

Early results from the pivotal trial substudy of the GORE EXCLUDER conformable endoprosthesis in angulated necks

ObjectiveTo report the investigational device exemption study 1-year clinical outcomes of the high neck angulation (HNA) substudy of the GORE EXCLUDER Conformable AAA Endoprosthesis (EXCC) for treatment of infrarenal abdominal aortic aneurysms (AAAs). MethodsThis study is a prospective, multicenter clinical trial conducted in the United States and included core laboratory assessment of imaging and independent event adjudication. Anatomical criteria for enrollment in the HNA substudy included infrarenal aortic neck angulation >60° and ≤90° with aortic neck length ≥10 mm. Primary safety end points included estimated blood loss of >1000 mL, death, stroke, myocardial infarction, bowel ischemia, paraplegia, respiratory failure, renal failure, and thromboembolic events. Primary effectiveness end points included technical success, absence from type I and III endoleaks, migration (≥10 mm), sac enlargement (≥5 mm), sac rupture, and conversion to open repair. ResultsBetween January 2018 and February 2022, 95 patients were enrolled in the HNA substudy across 35 sites. Of the 95 patients, 71 (74.7%) were male and the cohort average age was 74.4 years. The mean infrarenal proximal aortic neck angle was 71.6° and the mean AAA size was 62.9 mm. Overall technical success was achieved in 93 patients (97.9%). Freedom from a primary safety end point through 30 days was 96.7%; 3 (3.3%) patients had an estimated blood loss of >1000 mL. Freedom from the primary effectiveness at 12 months was achieved in 94.8%. Four patients (4.3%) had a type IA endoleak; intervention after the procedure was not required and no subsequent interventions or sac enlargement were noted in these patients. At 12 months, 29 patients (39.7%) experienced a type II endoleak and 1 (1.3%) patient experienced AAA sac expansion of ≥5 mm. Through 12 months, 1 patient (1.3%) had a conversion to open surgical repair. There were no aneurysm-related deaths, ruptures, or migration through 12 months. ConclusionsThe investigational device exemption study demonstrates safety and effectiveness of the GORE EXCLUDER Conformable AAA Endoprosthesis device in AAA with highly angulated necks (>60° and ≤90°) are preserved at the 12-month follow-up.

MASSIVE LATE ENDOLEAK TYPE IA, ASSOCIATED WITH SHOCK AND ACUTE ANEMIA: CONSERVATIVE SURGICAL TREATMENT

We present a case of type 1 endoleaks associated with massive hemorrhage and shock, treated with traditional open surgery. We present a 74-year-old male patient with a history of endovascular repair of abdominal aortic aneurysm 6 years ago, was admitted to the emergency department in shock and acute anemia, showing a type IA endoleak associated with retroperitoneal hematoma. Open repair was performed with the interposition of a Dacron™ prosthesis with preservation of the aortic endoprosthesis. Although in these cases of extreme urgency, it has been proposed the extraction of the endoprosthesis, which involves a procedure associated with high mortality, in this case, it was feasible a simple repair as was the interposition of prosthesis between proximal aorta and endoprosthesis. Endovascular repair of aortic aneurysm requires strict monitoring and a good selection of patients for this procedure since this late complication has a high mortality rate.

The Gore Viabahn balloon-expandable stent graft as bridging stent in complex endovascular aortic procedures at 3-years performs better in fenestrations

Complex endovascular procedures are now recognized as the gold standard treatments for extensive aortic diseases. Bridging stents (covered stents used to couple the aortic graft to the visceral vessels) play a pivotal role, yet there is currently no dedicated device available on the market. The aim of the study was to evaluate the midterm performance of the Gore Viabahn balloon-expandable (VBX) stent graft as a bridging stent for target visceral vessels (TVVs). Data from all consecutive patients who underwent a fenestrated and branched endovascular aortic repair and received the VBX stent graft as a bridging stent between July 2018 and September 2022 were prospectively collected and subsequently analyzed retrospectively. Primary end points included freedom from TVV instability and freedom from TVV-related reinterventions, both overall and in comparison between branched and fenestrated graft configurations. Secondary end points were overall survival, procedure and TVV-related (in an intent-to-treat basis) technical success, freedom from type IC/IIIC endoleak, and freedom from TVV patency loss. Sixty-three patients were treated with a fenestrated and branched endovascular aortic repair using the VBX stent graft as a bridging stent, of whom 47 (74.6%) presented an atherosclerotic aneurysm, 7 (11.1%) a post-dissecative aneurysm, and 9 (14.3%) an anastomotic pseudoaneursym or a type IA endoleak in a previous endovascular aorticrepair. Included in the aortic repair were 231 of 243 (95.1%) total visceral vessels. The intraoperative requirement of 13additional VBX stent grafts determined a TVV-related technical success of 94.4%. The mean follow-up was 26.1±16.4months. The estimated overall survival at 36 months was 73%± 7.5%. The estimated rates at 36 months for freedom from type IC/IIIC endoleaks and TVV primary patency were 90.6%± 3.9% and 99%± 0.7%, respectively. The estimated rate at 36 months for freedom from TVV instability was 92.1%± 3% and did not differ between branched and fenestrated configurations, whereas freedom from TVV-related reinterventions was 90.6%± 3.1% and significantly in favor of fenestrations (69.4% vs 96.8%, P< .001). Multivariate analyses confirmed fenestrated configuration as a protective factor against TVV-related reinterventions (hazard ratio: 0.079; 95% confidence interval: 0.016-0.403). The VBX stent graft proves to be a reliable bridging stent for complex aortic procedures involving both fenestrated and branched endografts. Although immediate results are deemed satisfactory, they favor fenestrations regarding the need of reinterventions through 3 years. The success of the procedure heavily relies on a thorough understanding of the unique characteristics of this stent.

The results of thoracic endovascular aortic repair for high-risk type B aortic dissection

Overview: Evaluating the efficacy of endovascular intervention in treatment of high-risk type B aortic dissection Methods: Review a series case of high-risk type B aortic dissection cases treated with endovascular intervention at Cho Ray Hospital from January 2020 to December 2022. Results: The study included a total of 30 patients with high-risk type B aortic dissection who underwent endovascular intervention meeting all sampling criteria. The average age was 53 years (26-73 years), with males accounting for 86.7%. The most common risk factor was hypertension (86.7%). Pain was the primary reason for hospital admission, with chest pain being the most frequent (80%). The most prevalent high-risk factors were false lumen diameter &gt; 22mm (66.7%), followed by aortic diameter &gt; 40mm (36.7%), and entry tear diameter &gt; 10mm (33.3%). Regarding intervention characteristics, the average stent graft length was 207.3mm, with proximal landing zones predominantly in zone 1 (23.3%), zone 2 (40%), and zone 3 (36.7%). Twenty-nine patients were continuously monitored for an average of 4.3 months, with a complication rate of 10% including endoleak type Ia (6.9%) and retrograde dissection (3.4%). Aortic remodeling was evidenced by a significant reduction in false lumen size (p&lt;0.001) Conclusion: Follow-up results show a low rate of complications and a high rate of aortic reconstruction post-intervention.

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.

Indication and Outcome of Late Open Conversion after Abdominal Endovascular Aortic Repair

ObjectiveEndovascular aortic repair (EVAR) has become the standard of care for patients with infrarenal aortic aneurysms over the last two decades. Endograft technology and treatment of complications like endoleaks, graft migration or graft occlusion developed over time. However, sometimes open surgical conversion maybe required. Our aim was to analyze the indications, the technical aspects and outcomes in patients who underwent open conversion after EVAR with different types and generations of endografts. MethodsThis retrospective single-center study reviewed all patients who underwent EVAR from 2004 to 2020. Open surgical conversions > 1 month post EVAR were identified. Conversions for graft infection were excluded. Indications for conversion and operative technique were analyzed. Primary endpoint of the study was 30-day mortality. Secondary endpoints were re-interventions and follow up mortality. ResultsDuring 2004 and 2020, 443 consecutive EVARs were performed, and 28 patients required open surgical conversion, with an additional 3 referred from other hospitals (N=31). The median age was 75 (range 58-93); 94% were male. Conversion was performed after a median time of 55 months (range 16 - 209). Twenty patients underwent elective and 11 emergency conversion. Indications for open conversion were graft migration respectively disease progression with endoleak type Ia and/ or Ib in 52 % (16/31) and sac expansion due to endoleak type II in 26 % (8/31). Of the 31 patients, 17 (55%) had at least one previous endovascular re-intervention. All patients met the device-specific instructions for use for each implanted endograft.In-hospital intervention rate was 16 % (5/31). 30-day mortality rate was 3% (1/31) with one patient died due to multi-organ failure after rupture with complete endograft replacement. Five patients (16%) died during follow-up. Mid-term follow-up was 47.5 months (range 24 -203) with estimated cumulative survival rates of 97%, 89%, and 84%, at 1, 3, and 5 years, respectively. ConclusionLate open conversion remains a valuable treatment option and can be performed safely in elective and emergency setting with a low early mortality. Lifelong surveillance, and prompt intervention when necessary are essential in ensuring optimal outcomes after EVAR and preventing the need for emergent conversions.

Endovascular treatment for Stanford type B aortic dissection in Marfan syndrome patients: a series of 23 cases

Objective: To evaluate the clinical outcomes of thoracic endovascular aortic repair (TEVAR) in the treatment of Stanford type B aortic dissection (TBAD) in Marfan syndrome patients who had no history of aortic arch replacement. Methods: This is a retrospective case-series study. From January 2009 to December 2019,the clinical data of Marfan syndrome patients who underwent TEVAR for TBAD at the Department of Vascular Surgery were collected. A total of 23 patients were enrolled,including 15 males and 8 females. The age was (38.0±11.0) years (range:24 to 56 years). Among them,12 patients had history of ascending aortic surgery. Details of TEVAR,perioperative complications and reintervention were recorded and survival rate was analyzed by Kaplan-Meier curve. Results: Technical success was 91.3% (21/23). Two patients with technical failure were as follows:one patient had type Ⅰa endoleak at the completion angiography,which healed spontaneously during the follow-up,and the other patient suffered aortic intimal intussusception after the deployment of the first stent-graft, and the second stent-graft was deployed. However, type Ⅲ endoleak was detected,which disappeared during the follow-up. One patient died during hospitalization. The median follow-up time (M(IQR)) was 60 (48) months (range:12 to 132 months). Reintervention was performed on 7 patients,including 3 distal stent-graft-induced new entry,2 distal aortic dilation,1 Ⅰa endoleak and 1 retrograde type A aortic dissection,respectively. Five-year cumulative survival rate was 86.7% (95%CI:86.6% to 86.8%) and the 5-year freedom from reintervention rate was 81.8% (95%CI:61.8% to 92.8%). Conclusions: TEVAR is feasible in the treatment of TBAD in Marfan syndrome patients who has no history of aortic arch replacement. It has high technical success rate and low perioperative complication.

Early multicentric outcomes of the on-label and CE-marked combination of the Endurant with the Radiant chimney graft for the chimney endovascular aortic repair (EnChEVAR): The LaMuR Registry.

The aim of this study was to evaluate the early results of the CE-marked standardized device combination consisting of Endurant and the Radiant chimney graft (En-ChEVAR) for the treatment of juxtarenal aortic aneurysms. We analyzed multicentric non-industry sponsored case series evaluating the EnChEVAR technique for patients treated between December 2022 and February 2024. Clinical, perioperative procedure-related and radiological data were collected. The primary outcome measure was the freedom of a type Ia gutter-related endoleak at postoperative computed tomography angiography (CTA). Secondary outcome measures included early type Ia endoleak-related reinterventions, target vessel complications including dissection or loss of target vessel, major adverse events, and mortality. Continuous variables were presented as median (interquartile range [IQR]) and categorical variables as count and percentage. Ten patients were included in the present study. Eight (80%) were males, in nine cases a single chimney was implanted, and the other one was a double chimney graft placement. The treated aneurysms had an infrarenal neck length of 3.4 (1.2) mm. The rate of main body oversizing was 30%. The new neck length after chimney graft placement was 18 (3) mm. The median procedural time was 130 (17) mm, contrast medium use was 109 (26) mL, radiation time was 45 (12) min. The technical success was 100%. No type Ia endoleak was detected at the postoperative CTA. There were no target vessel issues. No major adverse events or death were observed. First reported cohort of patients treated with EnChEVAR demonstrated reproducible clinical and procedural outcomes within the 3 vascular centers with total exclusion of the aneurysms, patent renal arteries, and no evidence of gutter-related type IA endoleak. Further evidence with larger sample size of treated patients and longer follow-up are needed.

Early survival benefit of a low-profile endograft in blunt traumatic aortic injury

ObjectiveThe aim of this study was to demonstrate the safety and effectiveness of a low-profile thoracic endograft (19-23 French) in subjects with blunt traumatic aortic injury. MethodsA prospective, multicenter study assessed the RelayPro thoracic endograft for the treatment of traumatic aortic injury. Fifty patients were enrolled at 16 centers in the United States between 2017 and 2021. The primary endpoint was 30-day all-cause mortality. ResultsThe cohort was mostly male (74%), with a mean age of 42.4 ± 17.2 years, and treated for traumatic injuries (4% Grade 1, 8% Grade 2, 76% Grade 3, and 12% Grade 4) due to motor vehicle collision (80%). The proximal landing zone was proximal to the left subclavian artery in 42%, and access was primarily percutaneous (80%). Most (71%) were treated with a non-bare stent endograft. Technical success was 98% (one early type Ia endoleak). All-cause 30-day mortality was 2% (compared with an expected rate of 8%), with an exact two-sided 95% confidence interval [CI] of 0.1%, 10.6% below the performance goal upper limit of 25%. Kaplan-Meier analysis estimated freedom from all-cause mortality to be 98% at 30 days through 4 years (95% CI, 86.6%-99.7%). Kaplan-Meier estimated freedom from major adverse events, all-cause mortality, paralysis, and stroke, was 98.0% at 30 days and 95.8% from 6 months to 4 years (95% CI, 84.3%-98.9%). There were no strokes and one case of paraplegia (2%) during follow-up. ConclusionsRelayPro was safe and effective and may provide an early survival benefit in the treatment of blunt traumatic aortic injury.

Differences in In-Hospital and Follow-Up Outcomes Between Non-A Non-B Aortic Dissection and Type B Aortic Dissection Treated by Endovascular Based Treatment.

Non-A non-B aortic dissection (AD) is a rare and life-threatening medical emergency, and it has been controversial whether it should be managed as type B aortic dissection (TBAD). The study aims to compare in-hospital and follow-up outcomes between patients with non-A non-B AD and those with TBAD treated by endovascular based treatment (EBT). From January 2017 to December 2021, 96 consecutive patients with non-A non-B AD met the inclusion criteria and underwent EBT. Patients with TBAD were matched to patients with non-A non-B AD at a 1:1 ratio using propensity score matching analysis to correct for baseline confounding factors. The primary endpoint was all-cause mortality. Aortic-related events were defined as dissection-related death, aortic rupture, retrograde type A aortic dissection, reintervention, and type Ia endoleak. Patients with non-A non-B AD required more TEVAR-related adjunctive procedures compared to TBAD patients during EBT and they required a longer ICU length of stay (36.0 vs 24.0 hours, P < .05) as well as a longer hospitalization (8.0 vs 7.0 days, P < .05) after EBT. There was no statistical difference in overall survival after EBT for patients with TBAD and non-A non-B AD. However, compared to patients with TBAD, non-A non-B AD patients had a higher rate of reintervention and experienced more aortic-related late events during follow-up. Patients with non-A non-B acute AD who are treated with EBT do not have higher in-hospital or follow-up mortality rates compared to patients with type B AD. However, there is an increased risk of reintervention and aortic-related late events after the intervention during follow-up.

Mid-term results of "off-label" use of the Endurant stentgraft in patients with infrarenal abdominal aortic aneurysms.

EVAR is the preferred treatment modality for patients with an infrarenal abdominal aortic aneurysm with suitable anatomy. Each manufacturer of aortic stentgrafts has specific anatomic requirements. In some patients, it is not possible to adhere to the instructions for use, but alternative treatment is also not possible. In these patients, EVAR can be performed outside instructions for use. In this study, all consecutive patients in whom an Endurant II or IIS stentgraft was used between 1 January and 31 December were reviewed. We compared the two patient groups in whom this stentgrafts was used outside and inside instructions for use. Patients with planned adjuvant therapy, for example, chimney procedure or iliac side branches, were excluded. In 74 of 178 (41.6%) patients, the instructions for use were not adhered. The main reason was pathology of the aortic neck. There were more patients with type IA endoleak, this difference was borderline significant (p = .06). There were more patients with limb occlusion in the early postoperative period, but at the end of the follow-up period, the incidence was comparable. Aneurysm-related mortality and all-cause mortality were comparable in both groups. In this study, real-life experience with the Endurant II and IIS stentgraft is described. Non-adherence with instructions for use was associated with a higher risk of endoleak type IA (p = .06). In the early postoperative period, there were more patients with limb occlusion; this finding was not observed anymore at the end of the follow-up period.

Long-term outcomes of chimney endovascular aneurysm repair procedure for complex abdominal aortic pathologies

ObjectiveThe aim of this study was to update our earlier experience and to evaluate long-term outcomes of chimney endovascular aortic repair performed for selected cases with complex abdominal aortic aneurysm. MethodsA single-center retrospective cohort study was conducted on 51 consecutive patients who underwent chimney endovascular aortic repair procedure, deemed unfit for open surgical repair and fenestrated endovascular aneurysm repair, from October 2009 to November 2019. Kaplan-Meier analyses were used to assess the estimated overall survival, freedom from aneurysm related mortality, freedom from reintervention, freedom from target vessel instability, and freedom from type Ia endoleaks. ResultsFifty-one patients (mean age, 77.1 ± 7.5 years) with a mean preoperative maximum aneurysm diameter of 74.2 ± 20.1 mm were included. Mean follow-up duration was 48.6 months (range, 0-136 months). Estimated overall survival at 5 and 7 years was 36.3% ± 7.1% and 18.3% ± 6.0%, respectively. Freedom from aneurysm-related mortality was 88.6% ± 4.9% at 7 years. Estimated freedom from type Ia endoleaks at 7 years was 91.8% ± 3.9%. A total of 21 late reinterventions were performed in 17 patients (33%). Most of them were performed to treat type II endoleaks with sac growth (47.6%; n = 10) and type Ib endoleak (23.8%; n = 5). Estimated freedom from reintervention at 7 years was 56.3% ± 7.9%. Estimated freedom from target vessel instability at 7 years was 91.5% ± 4.1%. ConclusionsThe 7-year results of chimney endovascular aortic repair procedures performed in our center confirm the long-term safety and effectiveness of this technique in a series of high-risk patients with large aneurysms. The present study has, to the best of our knowledge, the longest follow-up for patients treated with chimney endovascular aortic repair, and it provides data to the scarce literature on the long-term outcomes of this procedure, showing acceptable to good long-term results.

“Loss of landing zone”—Stabilizing endovascular treatment solutions in the aortic arch after thoracic endovascular aortic repair

Addressing proximal complications that arise after endovascular aortic repair for type B aortic dissection, such as type Ia endoleaks, “bird-beaking” of the thoracic endovascular aortic repair (TEVAR) stent, retrograde type A dissection, and postdissection aneurysms, bears considerable complexities. We present a novel and safe method for open arch repair that can ensure a secure and efficient approach for TEVAR complications. The key element of the operative technique is approximating the grafted stent portion to the aortic wall and the arch prosthesis. The technique has successfully been implemented in 11 patients, who received secondary open arch repair from 2019 to 2022 after TEVAR for type B dissection. Our objective is not only to introduce this reliable concept but also to provide a comprehensive demonstration of its advantages and disadvantages compared with currently used open treatment methods and discuss patient outcomes after secondary open arch repair.