Use Of Endovascular Aneurysm Repair Research Articles

Persistent High Long-term Excess Mortality After Elective AAA Repair Especially in Women: A Large Population-based Study.

The aim of this time-trend analysis is to estimate long-term excess mortality and associated cardiovascular risk for abdominal aortic aneurysm (AAA) patients after elective repair while addressing the changes in AAA management and patient selection over time. Despite the intensification of endovascular aneurysm repair and cardiovascular risk management, Swedish population data suggest that AAA patients retain a persistently high long-term mortality after elective repair. The question is whether this reflects suboptimal treatment, a changing patient population over time, or a national phenomenon. Nationwide time-trend analysis including 40,730 patients (87% men) following elective AAA repair between 1995 and 2017. Three timeframes were compared, each reflecting changes in the use of endovascular aneurysm repair and intensification of cardiovascular risk management. Relative survival analyses were used to estimate disease-specific excess mortality. Competing risk of death analysis evaluated the risk of cardiovascular versus noncardiovascular death. Sensitivity analysis evaluated the impact of changes in patient selection over time. Short-term excess mortality significantly improved over time. Long-term excess mortality remained high with a doubled mortality risk for women (relative excess risk=1.87, 95% CI: 1.73-2.02). Excess mortality did not differ between age categories. The risk of cardiovascular versus noncardiovascular death remained similar over time, with a higher risk of cardiovascular death for women. Changes in patient population (ie, older and more comorbid patients in the latter period) marginally impacted excess mortality (2%). Despite changes in AAA care, patients retain a high long-term excess mortality after elective repair with a persistent high cardiovascular mortality risk. In this, a clear sex - but no age - disparity stands out.

Referral Centre Experience with Infected Abdominal Aortic Endograft Explantation

The increasing use of endovascular aneurysm repair (EVAR) appears to be associated with the burden of vascular endograft infections. Complete stent graft explantation is recommended but leads to significant mortality. This study aimed to assess the technical challenges, complications, and mortality rate following infected endograft explantation. Patients who underwent abdominal aortic endograft explantation for infection at the Bordeaux University Hospital from July 2008 to December 2020 were included retrospectively in this single centre observational study. The diagnosis was established based on the MAGIC criteria. The primary endpoint was 30 day mortality. Secondary endpoints were 90 day and in hospital mortality, survival, and re-infection. Thirty-four patients were included, median age 69 years (interquartile range [IQR] 65, 76), with four (12%) treated as an emergency. The median time from EVAR to explantation was 17.5 months (4.5 - 36.3). In situ reconstruction was carried out with prosthetic grafts in 24 patients (71%, including 23 antimicrobial grafts combining silver and triclosan), and biological grafts in 10 (five femoral veins, four arterial allografts, three bovine patches, one biosynthetic graft). Seventeen aorto-enteric fistulae (AEnF) were addressed with direct repair of the intestinal tract (n= 10/17; 59%) or resection and anastomosis (n= 7/17; 41%). The culture was polymicrobial in 12 patients (35%) and remained sterile in four (12%). The 30 day and in hospital mortality rates were 21% (n= 7) and 27% (n= 9). Twenty-five patients (73%) presented with early post-operative complications, requiring 16 revision procedures (47%). Over a median follow up of 16.2 months (IQR 8.3, 33.6), the mortality rate was 35% (n= 12; 11 aortic related; 32%), with two re-infections (6%), both after biological reconstruction (one for an AEnF). Early morbidity and mortality remain high after complete infected endograft explantation, even in a high volume centre. Comparison with other treatment modalities in large multicentre cohorts might be of interest.

Cloud-based Fusion Imaging Improves Operative Metrics During Fenestrated Endovascular Aneurysm Repair

Endovascular treatment of complex aortic pathology is associated with increases in procedural-related metrics including operative time and radiation exposure. Three-dimensional fusion imaging technology has decreased radiation dose and iodinated contrast use in endovascular aneurysm repair. The aim of this study is to report our institutional experience with use of a cloud-based fusion imaging platform in fenestrated endovascular aneurysm repair (FEVAR). A retrospective review of a prospectively maintained aortic database was performed to identify all patients who underwent commercially-available FEVAR (Zenith Fenestrated, Cook Medical, Bloomington, Ind) between 2013 and 2020, as well as all endovascular aneurysm repairs performed using Cydar EV Intelligent Maps (Cydar Medical, Cambridge, UK). The Cydar EV cohort was reviewed further to select all FEVAR performed with intelligent map guidance. Patient demographics, clinical, and procedural-related metrics were analyzed, with comparative analysis of FEVAR performed without and with the Cydar EV imaging platform. Patients were excluded from the comparative analysis if incomplete in the data set, or if documented history of prior open or endovascular abdominal aortic aneurysm repair. Over the 7-year study period 191 FEVAR were performed. The Cydar EV imaging platform was implemented in 2018 and used in 124 complex endovascular aneurysm repairs, including 69 consecutive FEVAR. A complete dataset was available on 137 FEVAR. With exclusions to select for de novo FEVAR, comparative analysis was performed on 53 FEVAR without and 63 with Cydar EV. Cohorts were similar with respect to patient demographics, medical comorbidities, and aortic aneurysm characteristics. No significant difference was noted between groups on major adverse postoperative events, length of stay, or length of intensive care unit stay. Use of the Cydar EV resulted in nonsignificant decreases in mean fluoroscopy time (69.3 minutes vs 66.2 minutes; P = .598), and a positive trend toward shorter operative times (204.4 minutes vs 186 minutes; P = .278). Notably, a statistically significant decrease in both iodinated contrast volume (104.7 mL vs 83.8 mL; P = .005), and patient radiation exposure via dose-area product (1,049,841 mGy/cm2 vs 630,990; P < .001) was observed in patients undergoing FEVAR with Cydar EV Intelligent Maps. Our aortic center has observed a trend toward shorter operative times, and significant decreased in both iodinated contrast use and radiation exposure during FEVAR with the use of Cydar EV Intelligent Maps. Intelligent map guidance improves the efficiency of complex endovascular aneurysm repair, providing a safer intervention for both patient and practitioner.

Meta-analysis finds recurrent infection is more common after endovascular than after open repair of infected abdominal aortic aneurysm.

Controversy has continued regarding the use of endovascular aneurysm repair (EVAR) vs open aneurysm repair (OAR) for infected abdominal aortic aneurysms (AAAs). In the present study, we investigated the comparative outcomes of EVAR and OAR for the treatment of infected AAAs. We conducted a systematic review and meta-analysis using the MEDLINE and EMBASE databases through May 2021. We included studies that had described both EVAR and OAR for the treatment of infected AAAs. The primary endpoints were the rates of recurrent infection and related rupture and/or death. Perioperative and 1-year mortality and readmissions and reinterventions were also analyzed. Fourteen observational studies describing a total of 1203 patients (EVAR, 359 [29.8%]; OAR, 844 [70.2%]) were eligible for qualitative analysis. The baseline characteristics included diabetes mellitus (33.2%), fever at presentation (71.6%), rupture at diagnosis (26.1%), and positive blood cultures (52.5%). The mean follow-up period ranged from 12 to 40months. The use of EVAR became more prevalent in recent years (2016-2020, 32.4%) compared with the former period (2010-2015, 13.8%; P< .0001). Fenestrated, branched, or concomitant visceral debranching EVAR was performed in 6.1% of cases. In OAR, surgical debridement was consistently performed, and in situ reconstruction was applied in 82.2% and an omental flap in 51.5%. In nine studies considered for quantitative analysis, the patients' background (EVAR, n= 264; OAR, n= 274) were statistically balanced. The crude rates of recurrent infection and related rupture or death were 13.6% (95% confidence interval [CI], 8.8%-18.5%) and 4.9% (95% CI 1.8%-8.0%), respectively. The pooled analyses depicted significantly higher rates of recurrent infection after EVAR than after OAR (relative risk [RR], 2.42; 95% CI, 1.80-3.27; P< .0001; I2= 0%). Recurrent infection-related rupture or death (RR, 1.51; 95% CI, 0.70-3.23; P= .29; I2= 0%), perioperative death (RR, 0.80; 95% CI, 0.39-1.65; P= .55; I2= 35%), 1-year mortality (hazard ratio, 1.12; 95% CI, 0.97-1.28; P=.13; I2= 0%), and readmission or reintervention (RR, 1.16; 95% CI, 0.74-1.82; P=.52; I2= 0%) were not significantly different statistically between the two groups. Funnel plots showed no evidence of publication bias. Sensitivity analyses of leave-one-out meta-analysis confirmed higher rates of recurrent infection after EVAR. EVAR has become more prevalent as the initial treatment of infected AAAs. Although operative and 1-year survival were similar between OAR and EVAR groups, recurrent infection was more frequent after EVAR. This limitation should be weighed in selecting patients for EVAR in infected AAAs. Postoperative graft and infection surveillance are critical, especially after EVAR.

Comparison of Operative Characteristics and Outcomes After Infected Endovascular and Open Surgical Abdominal Aortic Graft Excision

The national rates of open aortic repair (OAR) are declining owing to the increasing use of endovascular aneurysm repair (EVAR); however, both strategies can result in aortic graft infection (AGI). AGI is a devastating complication associated with significant morbidity and mortality; however, the technical elements of treating an infected EVAR can further complicate surgical extirpation. To date, no studies have compared, to the best of our knowledge, infected EVAR and OAR graft removal. Therefore, we analyzed our experience with AGI and assessed the differences in patient characteristics, operative strategies, and short-term outcomes between infected EVAR and OAR graft excision.

Simultaneous Laparoscopic Cholecystectomy and Endovascular Infrarenal Aortic Aneurysm Repair.

Background/Aim: With the increasing use of endovascular aneurysm repair (EVAR) and the availability of laparoscopic cholecystectomy (LC) for treating abdominal aortic aneurysms (AAA) and cholelithiasis, respectively, the association between these elective treatments is not yet well-defined. Thus, this study aimed to evaluate the results of elective and simultaneous EVAR and LC.Methods: Thirteen patients (mean age, 72 years) with concomitant large and asymptomatic AAA and asymptomatic cholelithiasis underwent simultaneous EVAR and LC.Results: Post-operative mortality was absent, and the morbidity rate was 7%. The mean total duration of the procedure was 142 min. The mean duration of fluoroscopy was 19 min, and the mean radiation dose was 65 mGy. The mean amount of iodinated contrast injected was 49 mL. The timing of oral fluid intake was 28 h (range, 24–48 h) and that of the oral low-fat diet was 53 h (range, 48–72 h). No patient presented with an aortic graft infection during the entire follow-up period (mean duration, 41 months). The mean length of post-operative hospital stay was 6 days (range, 5–8 days). Late survival was 85%, and the exclusion of AAA was 100%.Conclusion: Simultaneous EVAR and LC can be performed safely, allowing effective and durable treatment under both AAA and cholelithiasis conditions.

Effects of hospital preference for endovascular repair on postoperative mortality after elective abdominal aortic aneurysm repair: analysis of the Dutch Surgical Aneurysm Audit.

BackgroundIncreased use of endovascular aneurysm repair (EVAR) and reduced open surgical repair (OSR), has decreased postoperative mortality after elective repair of abdominal aortic aneurysms (AAAs). The choice between EVAR or OSR depends on aneurysm anatomy, and the experience and preference of the vascular surgeon, and therefore differs between hospitals. The aim of this study was to investigate the current mortality risk difference (RD) between EVAR and OSR, and the effect of hospital preference for EVAR on overall mortality.MethodsPrimary elective infrarenal or juxtarenal aneurysm repairs registered in the Dutch Surgical Aneurysm Audit (2013–2017) were analysed. First, mortality in hospitals with a higher preference for EVAR (high-EVAR group) was compared with that in hospitals with a lower EVAR preference (low-EVAR group), divided by the median percentage of EVAR. Second, the mortality RD between EVAR and OSR was determined by unadjusted and adjusted linear regression and propensity-score (PS) analysis and then by instrumental-variable (IV) analysis, adjusting for unobserved confounders; percentage EVAR by hospital was used as the IV.ResultsA total of 11 997 patients were included. The median hospital rate of EVAR was 76.6 per cent. The overall mortality RD between high- and low-EVAR hospitals was 0.1 (95 per cent −0.5 to 0.4) per cent. The OSR mortality rate was significantly higher among high-EVAR hospitals than low-EVAR hospitals: 7.3 versus 4.0 per cent (RD 3.3 (1.4 to 5.3) per cent). The EVAR mortality rate was also higher in high-EVAR hospitals: 0.9 versus 0.7 per cent (RD 0.2 (−0.0 to 0.6) per cent). The RD following unadjusted, adjusted, and PS analysis was 4.2 (3.7 to 4.8), 4.4 (3.8 to 5.0), and 4.7 (4.1 to 5.3) per cent in favour of EVAR over OSR. However, the RD after IV analysis was not significant: 1.3 (−0.9 to 3.6) per cent.ConclusionEven though EVAR has a lower mortality rate than OSR, the overall effect is offset by the high mortality rate after OSR in hospitals with a strong focus on EVAR.

Image-Based Displacements Analysis and Computational Blood Dynamics after Endovascular Aneurysm Repair

To examine intraheartbeat displacements (IHD) and geometrical changes of endografts for abdominal aortic aneurysm repair over the course of years, defined as follow-up displacements (FUD), and to correlate them with computational fluid dynamics (CFD). Despite the widespread use of endovascular aneurysm repair (EVAR), we still know little about endograft behavior after deployment. Two cases, treated with either expanded polytetrafluoroethylene on a nitinol stent frame (PI) or with woven polyester fabric sutured to a stainless-steel Z stent skeleton (PII), were submitted to dynamic computed tomography angiography at 1, 12, and 60months after implantation. After segmentation, IHD were computed as displacements of the reconstructed surface with respect to the diastolic instant. Similarly, FUD were studied using imaging techniques that align temporal successive segmentations. In addition, numerical simulations for blood dynamics were performed to compute viscous forces, specifically wall shear stress and time-averaged wall shear stress (TAWSS). IHD analysis showed slight translations without deformation for the PI endograft with respect to the stiffer stainless-steel endograft behavior of PII. FUD showed in PI motion of the metallic struts mainly focused on the distal main body of the endograft and in the zone overlapping with iliac branches. In PII, we observed a huge FUD in the middle and inferior-anterior regions of the main body. CFD analysis revealed changes of velocity patterns associated with remodeling of the iliac zone for PI and of the main body region for PII, where flow impinges the lumen wall and progressively induces deformation of the endograft wires. Measurement of TAWSS demonstrated flow disturbances in the enlarged region correlated with displacement analysis. Image-based displacement analysis associated with CFD enabled very subtle evaluations of endograft behavior on different temporal scales. This kind of study could be helpful both for physicians, forecasting evolution during the life span of the endograft, and manufacturers, giving them useful information about endograft implant performance and design.

Safety in numbers as administrative data supports the use of endovascular aneurysm repair in ruptured abdominal aortic aneurysms

A ruptured abdominal aortic aneurysm (rAAA) remains one of the most challenging, morbid, and mortal conditions that confronts a vascular surgeon. A number of patient-, surgeon-, and systems-based factors determine whether the optimal approach to care for these challenging patients is endovascular aneurysm repair (EVAR) or open surgical repair (OSR). In this issue of the Journal, Salata et al1 compare the short- and long-term results of EVAR and OSR for rAAA in Ontario between 2003 and 2016. They demonstrate that EVAR is associated with significant benefit in 30-day mortality and a reduction in major adverse cardiac events.

Paradigm shifts in abdominal aortic aneurysm management based on vascular registries.

Abdominal aortic aneurysm (AAA) is a relatively common and potentially fatal disease. The management of AAA has undergone extensive changes in the last two decades. High quality vascular surgical registries were established early and have been found to be instrumental in the evaluation and monitoring of these changes, most notably the wide implementation of minimally invasive endovascular surgical technology. Trends over the years showed the increased use of endovascular aneurysm repair (EVAR) over open repair, the decreasing perioperative adverse outcomes and the early survival advantage of EVAR. Also, data from the early EVAR years changed the views on endoleak management and showed the importance of tracking the implementation of new techniques. Registry data complemented the randomized trials performed in aortic surgery by showing the high rate of laparotomy-related reinterventions after open repair. Also, they are an essential tool for the understanding of outcomes in a broad patient population, evaluating the generalizability of findings from randomized trials and analysing changes over time. By using large-scale data over longer periods of time, the importance of centralization of care to high-volume centres was shown, particularly for open repair. Additionally, large-scale databases can offer an opportunity to assess practice and outcomes in patient subgroups (e.g. treatment of AAA in women and the elderly) as well as in rare aortic pathologies. In this review article, we point out the most important paradigm shifts in AAA management based on vascular registry data.

Are NICE processes fit for the evaluation of new interventional procedures?

The recent changes in the guidance issued by the National Institute for Health and Care Excellence (NICE) regarding the use of endovascular aneurysm repair highlight many of the difficulties faced in the evaluation and introduction of new interventional procedures. This paper questions whether the current processes for evaluation, largely based upon cost-utility analysis, are adequate to address the issues raised by such technologies. In particular, it considers the implications of rapidly evolving technologies, time preferences and process utilities for the evaluation and introduction of new procedures and devices.

Sustainability of Individual EndoAnchor Implants in Therapeutic Use to Treat Type Ia Endoleak After Endovascular Aneurysm Repair

Purpose: To investigate changes in penetration depths and angles of EndoAnchor implants with initially good penetration after therapeutic use in endovascular aneurysm repair. Materials and Methods: Patients were selected from the Aneurysm Treatment Using the Heli-FX Aortic Securement System Global Registry (ANCHOR; ClinicalTrials.gov identifier NCT01534819). Inclusion criteria were (1) EndoAnchor implantation to treat intraoperative or late type Ia endoleak and (2) at least 2 postoperative computed tomography angiography (CTA) scans. Exclusion criteria were the use of adjunct procedures. Based on these criteria, 54 patients (44 men) with 360 EndoAnchor implants were eligible for this analysis. Penetration depth of each EndoAnchor implant into the aortic wall was judged as (1) good (≥2-mm penetration), (2) borderline (<2 mm or when there was a gap between the endograft and the aortic wall), or (3) no penetration. The penetration depth and longitudinal angles of EndoAnchors with good penetration were investigated on the last available postprocedure CTA scan. Endoleaks were also analyzed. Results: EndoAnchor penetration on the first postprocedure CTA scan was good in 187 (51.9%), borderline in 69 (19.2%), and missing in 104 (28.9%). On the last CTA scan, 182 (97.4%) of the 187 initially well-positioned EndoAnchors remained good. Five (2.6%) EndoAnchors in 4 patients changed configuration over time (4 became borderline and 1 became nonpenetrating), all without any clinical sequelae. The median orthogonal angles of the EndoAnchor implants with good penetration on the first and last CTA scans were 92° [interquartile range (IQR) 85, 98] and 90° (IQR 84, 97), respectively (p=0.822); for longitudinal angles, medians of 85° (IQR 71, 96) and 84° (IQR 70, 96) were found (p=0.043). Of the 18 (33%) patients who had a type Ia endoleak on the first postprocedure CTA, 6 resolved over time. Median follow-up was 13 months, during which no new type Ia endoleak was found. Conclusion: Despite the small number of EndoAnchors analyzed, this study showed that the sustainability of EndoAnchor implants with initially good penetration is satisfactory at 1-year follow-up. The vast majority of EndoAnchor implants with good penetration initially remained in good position; <3% of implants became borderline or nonpenetrating, without any clinical consequence.

Early North American experience with the INCRAFT device

BackgroundSeveral low-profile grafts have been created for use in endovascular aneurysm repair in patients with small or difficult to access vessels. Our objective was to evaluate the outcomes of patients undergoing endovascular aneurysm repair with the INCRAFT device in a real-world North American setting. MethodsConsecutive patients undergoing INCRAFT implantation between March 2015 and December 2016 at two McGill University teaching hospitals were enrolled in a prospectively maintained registry. Clinical characteristic and perioperative outcomes were entered into the registry. Two authors performed anatomic measurements from preoperative and postoperative computed tomography angiograms and intraoperative angiograms independently. In cases of disagreement a consensus was reached. ResultsWe included 61 patients with a median follow-up of 363 days (mean, 344 ± 244 days). Minimum left and right access vessel sizes were 7.5 ± 1.7 mm and 7.4 ± 1.5 mm, respectively. More than 90% of grafts were implanted for aneurysm size or growth. Vessel access was percutaneous in 95% of cases. We had a mean length of stay of 0.88 ± 1.8 days with 57.3% of patients discharged the same day. There were 14 procedural type II endoleaks, 10 new type II leaks that were discovered during follow-up, and 11 that resolved for 77% of patients remaining endoleak free during follow-up. There were no 30-day mortalities. Three cancer-related deaths occurred during follow-up. Early complications included one access site repair for bleeding, one access site repair for dissection, and two aortounilateral conversions with femoral-femoral bypass owing to inadvertent ipsilateral gate cannulation. Long-term complications included one graft limb thrombosis, one intervention for type II endoleak with sac expansion that subsequently became infected and was explanted, and one intervention for a type III endoleak for an intervention. During follow-up, 95% of patients remained reintervention free. ConclusionsUse of the INCRAFT device in a real-world North American setting is relatively safe and effective, and is associated with a low rate of perioperative complications. However, we experienced early issues with inadvertent cannulation and deployment of the contralateral limb in the ipsilateral gate. Therefore, we recommend deploying the entire ipsilateral limb before cannulating the contralateral limb. Data with additional follow-up are needed to assess the long-term effectiveness of the INCRAFT device.

Simulation training streamlines the real-life performance in endovascular repair of ruptured abdominal aortic aneurysms

ObjectiveDifficulties in distributing endovascular experience among all operating room (OR) personnel prevented full-scale use of endovascular aneurysm repair (EVAR) in emergencies. To streamline the procedure of EVAR for ruptured aneurysm (rEVAR) and to provide this method even to unstable patients, we initiated regular simulation training sessions. MethodsThis is an observational study of 29 simulation sessions performed between January 2015 and December 2017. We analyzed the development of time from OR door to aortic balloon occlusion during simulations and OR door to needle times in real-life rEVARs as well as the outcome of the 185 ruptured abdominal aortic aneurysm (rAAA) patients who arrived at the university hospital between January 2013 and December 2017. A questionnaire was sent for simulation attendants before and after the simulation session. ResultsIn the first simulations, the door to occlusion time was 20 to 35 minutes. After adding a hemodynamic collapse to the simulation protocol, the time decreased to 10 to 13 minutes in the 10 recent simulations, including a 5-minute cardiopulmonary resuscitation (P = .01). The electronic questionnaire performed for attendees before and after the simulation session showed significant improvement in both confidence and knowledge of the OR staff regarding rEVAR procedure. In the real-life rEVARs, 75 of the 185 patients with rAAAs underwent EVAR. Among rEVAR patients, the median OR door to needle time was 65 minutes before and 16 minutes after the onset of simulations (P = .000). The overall 30-day mortality among all rAAA patients was 44.8% and 30.6% accordingly (P = .046). When patients who were turned down from the emergency surgery were excluded, the 30-day operative mortality was 39.2% and 25.1% during the periods, respectively (P = .051). The 30-day mortality was 16.2% after rEVAR and 40.6% after open surgery (P = .001). ConclusionsSimulation training for rEVAR significantly improves the treatment process in real-life patients and may enhance the outcome of rAAA patients.

Invited commentary

Invited commentary

Early experiences of endovascular aneurysm repair for ruptured abdominal aortic aneurysms.

PurposeThe use of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (r-AAA) is steadily increasing. We report early experiences of EVAR for r-AAA performed in two tertiary referral centers in Korea.MethodsWe retrospectively reviewed r-AAA patients treated by EVAR from May 2013 to December 2017. An EVAR-first strategy for r-AAA was adopted whenever feasible. The demographic information, anatomic characteristics, operative details, postoperative complications with special attention to abdominal compartment syndrome (ACS), and 30-day mortality were collected and analyzed.ResultsWe identified 13 patients who underwent EVAR for r-AAA. Mean age was 74.2 years and mean AAA size was 74.2 mm. Two patients underwent cardiopulmonary resuscitation at initial presentation. Bifurcated stent grafts were used in 12 out of 13 cases and physician-modified endografts with fenestrated/chimney techniques were performed in 2 cases with short neck. Successful stent graft deployment was achieved in all cases. Three patients were suspected of having ACS and 2 of them underwent laparotomy for decompression. The 30-day mortality was 7.7% (1 of 13), the only mortality being a patient that refused decompressive laparotomy for suspected ACS.ConclusionDespite the small numbers, the outcomes of EVAR for treatment of r-AAA were very promising, even in selected cases with unfavorable anatomy. These outcomes were achieved by a dedicated and well-trained team approach, and by use of high-end angiographic technology. Finally, ACS after EVAR is not uncommon, and requires a high index of suspicion as well as liberal use of decompressive surgery.

Early Experience with Snorkels and Chimneys for Expanding the Indications for Use of Endovascular Aneurysm Repair

Although fenestrated and branched devices for juxtarenal and paravisceral aneurysms are available worldwide, limited ultrasound availability has perpetuated widespread utilization of adjunctive techniques for the endovascular treatment of these aneurysms. The objective of the study is to report on the technical feasibility and short-term durability of parallel grafts for juxtarenal and paravisceral aneurysms. We performed a retrospective review of a prospectively collected endovascular aneurysm repair database, including all patients who underwent a parallel stent procedure. End points included were the following: (1) number of vessels snorkeled; (2) endoleaks; (3) morbidity and mortality; and (4) snorkel graft patency. Forty patients (85% male, mean 77.8years) were treated for primary aneurysms (26), para-anastomotic aneurysms (6) following prior open repair, and endoleaks (8) following prior endovascular repair. Sixty-nine visceral vessels were preserved. Bilateral femoral arteries were accessed, as well as the left upper extremity via percutaneous (n=5) brachial, open brachial (n=15), or open axillary (n=20) artery exposure with conduit. The mean length of surgery was 253min with median intensive care unit stay of 2days. There were 6 endoleaks noted, 8 access site complications, 1 perioperative death, and 3 branch vessel stent occlusions. We have a mean follow-up time of 17.6months (range 3-44). Parallel stent-graft repair for paravisceral aneurysms is feasible and has acceptable technical/clinical success and complication rates. Although long-term follow-up is still needed, this technique fills the gap in endovascular options for poor open surgical candidates in whom fenestrated devices are not available.

Mechanical performances of endovascular aneurysm repair strategies with main aortic and chimney grafts.

The use of endovascular aneurysm repair (EVAR) strategies for the treatment of complex aortic pathologies is a major area of investigation in modern surgery. EVAR strategies using fenestrated or branched devices provide alternatives to open surgery for patients with aortic pathologies with visceral branch involvement, but their applications have some major limitations. To extend endovascular repair to patients whose anatomy is unfit for branched or fenestrated stent grafts or open repair, parallel graft techniques using chimney grafts (CGs) have been proposed. Several recent series have confirmed that the midterm durability of CGs is similar to that of other endovascular repair techniques. However, the risk of a persistent type 1 endoleak, or gutter endoleak, is a major concern for their further application. In addition, the combinations of CGs with various brands of main aortic graft (MAG) that are applicable for use in patients remain unclear. This study aimed to determine the radial forces developed by different brands of MAG and their effects on CGs, and the real gutter condition produced between the CGs and main stent grafts.

Outcomes for symptomatic abdominal aortic aneurysms in the American College of Surgeons National Surgical Quality Improvement Program

Historically, symptomatic abdominal aortic aneurysms (AAAs) were found to have intermediate mortality compared with asymptomatic and ruptured AAAs; but with wider use of endovascular aneurysm repair (EVAR), a more recent study suggested that mortality of symptomatic aneurysms was similar to that of asymptomatic AAAs. These prior studies were limited by small numbers. The purpose of this study was to evaluate the mortality and morbidity associated with symptomatic AAA repair in a large contemporary population. All patients undergoing infrarenal AAA repair were identified in the 2011 to 2013 American College of Surgeons National Surgical Quality Improvement Program, vascular surgery targeted module. We excluded acute conversions to open repair and those for whom the surgical indication was embolization, dissection, thrombosis, or not documented. We compared 30-day mortality and major adverse events for asymptomatic, symptomatic, and ruptured AAA repair, stratified by EVAR and open repair, with univariate analysis and multivariable logistic regression. There were 5502 infrarenal AAAs identified, 4495 asymptomatic aneurysms (830 open repair, 3665 [82%] EVAR), 455 symptomatic aneurysms (143 open repair, 312 [69%] EVAR), and 552 ruptured aneurysms (263 open repair, 289 [52%] EVAR). Aneurysm diameter was similar between asymptomatic and symptomatic AAAs when stratified by procedure type, but it was larger for ruptured aneurysms (EVAR: symptomatic 5.8± 1.6cm vs ruptured 7.5± 2.0cm [P< .001]; open repair: symptomatic 6.4± 1.9cm vs ruptured 8.0± 1.9cm [P< .001]). The proportion of women was similar in symptomatic and ruptured AAAs (27% vs 23%, respectively; P= .14) but lower in asymptomatic AAAs (20%; P< .001). Symptomatic AAAs had intermediate 30-day mortality compared with asymptomatic and ruptured aneurysms after both EVAR (1.4% asymptomatic vs 3.8% symptomatic [P= .001]; symptomatic vs 22% ruptured [P< .001]) and open repair (4.3% asymptomatic vs 7.7% symptomatic [P= .08]; symptomatic vs 34% ruptured [P< .001]). After adjustment for age, gender, repair type, dialysis dependence, and history of severe chronic obstructive pulmonary disease, patients undergoing repair of symptomatic AAAs were twice as likely to die within 30days compared with those with asymptomatic aneurysms (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.3-3.5). When stratified by repair type, the effect size and direction of the ORs were similar (EVAR: OR, 2.4 [95% CI, 1.2-4.7]; open repair: OR, 1.8 [95% CI, 0.86-3.9]) although not significant for open repair. Patients with ruptured aneurysms had a sevenfold increased risk of 30-day mortality compared with symptomatic patients (OR, 6.5; 95% CI, 4.1-10.6). Patients with symptomatic AAAs had a twofold increased risk of perioperative mortality compared with patients with asymptomatic aneurysms undergoing repair. Furthermore, patients with ruptured aneurysms have a sevenfold increased risk of mortality compared with patients with symptomatic aneurysms.

The impact of endovascular aneurysm repair on mortality for elective abdominal aortic aneurysm repair in England and the United States

Procedural mortality is of paramount importance for patients undergoing elective abdominal aortic aneurysm (AAA) repair. Previous comparative studies have demonstrated international differences in the care of ruptured AAA. This study compared the use of endovascular aneurysm repair (EVAR) and in-hospital mortality for elective AAA repair in England and the United States. The English Hospital Episode Statistics and the U.S. Nationwide Inpatient Sample (NIS) were interrogated for elective AAA repair from 2005 to 2010. In-hospital mortality and the use of EVAR were analyzed separately for each health care system, after within-country risk adjustment for age, gender, year, and an accepted national comorbidity index. The study included 21,272 patients with AAA in England, of whom 86.61% were male, with median (interquartile range) age of 74 (69-79) years. There were 196,113 AAA patients in the United States, of whom 76.14% were male, with median (interquartile range) age of 73 (67-78) years. In-hospital mortality was greater in England (4.09% vs 1.96 %; P< .01) and EVAR less common (37.33% vs 64.36%; P< .01). These observations persisted in age- and gender-matched comparison. In both countries, lower mortality and greater use of EVAR were seen in centers performing greater numbers of AAA repairs per annum. In England, lower mortality and greater use of EVAR were seen in teaching hospitals with larger bed capacity. In-hospital survival and the uptake of EVAR are lower in England than in the United States. In both countries, mortality was lowest in high-caseload centers performing a greater proportion of cases with endovascular repair. These common factors suggest strategies for improving outcomes for patients requiring elective AAA repair.