1
|
Koudounas G, Bontinis V, Giannopoulos S, Bontinis A, Tassiopoulos A, Karkos CD. Rupture after previous endovascular abdominal aortic aneurysm repair: A meta-analysis and meta-regression analysis of factors influencing perioperative mortality. J Vasc Surg 2025:S0741-5214(25)00610-X. [PMID: 40120725 DOI: 10.1016/j.jvs.2025.02.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2024] [Revised: 01/22/2025] [Accepted: 02/05/2025] [Indexed: 03/25/2025]
Abstract
OBJECTIVE To document the clinical presentation, management, and outcome of patients presenting with late rupture of abdominal aortic aneurysm after previous endovascular aneurysm repair (EVAR) and to investigate which factors may influence the perioperative mortality. METHODS A systematic review and meta-analysis of relevant studies was undertaken to February 2024 in conformity with the PRISMA guidelines. We included studies reporting on either EVAR or open surgical repair (OSR) of late rupture (>30 days) after previous EVAR. The primary end point was perioperative (in-hospital or 30-day) mortality. A random effects meta-analysis was conducted and a meta-regression was subsequently performed to examine the impact of several variables on perioperative mortality. RESULTS Thirty studies (743 patients, 746 ruptures) were included. The cumulative incidence of rupture after EVAR during a mean 5-year follow-up was 1.5%. The mean time from the index EVAR to rupture was 48 months (range, 16-81 months). The mean compliance with follow-up was 68% (95% confidence interval [CI], 58-77) and 32% (95% CI, 24-40) of the cases had at least one previous aneurysm-related reintervention. Type I and III endoleaks were the predominant causes of rupture (88%). Approximately one-third of the patients (37%; 95% CI, 28-47) were hemodynamically unstable. Of those undergoing an operation, 247 patients (38%) were managed endovascularly and 409 (62%) by OSR. The pooled perioperative mortality was 29.5% (30 studies; 95% CI, 23.8-35.8) and was significantly lower in the endovascular subgroup (20 studies; risk ratio, 0.62; 95% CI, 0.44-0.86). Meta-regression demonstrated that perioperative mortality seems to fall in recent years (-0.0545; P = .04), to decrease in larger series in the endovascular subgroup (-0.0375; P = .01), and to be significantly higher when total endograft explantation is required in the OSR subgroup (0.0121; P = .03). CONCLUSIONS Late rupture after previous EVAR is a devastating event with a considerable risk for death. EVAR is associated with a significantly lower perioperative mortality and should be preferred whenever feasible. When OSR is required, total endograft explantation carries a higher mortality and, therefore, preserving functional parts of the endograft should be encouraged.
Collapse
Affiliation(s)
- Georgios Koudounas
- Vascular Unit, 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece; Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Vangelis Bontinis
- Department of Vascular Surgery, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Alkis Bontinis
- Department of Vascular Surgery, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Apostolos Tassiopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Christos D Karkos
- Vascular Unit, 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece.
| |
Collapse
|
2
|
Bruijn LE, Louhichi J, Veger HTC, Wever JJ, van Dijk LC, van Overhagen H, Hamming JF, Statius van Eps RGS. Identifying Patients at High Risk for Post-EVAR Aneurysm Sac Growth. J Endovasc Ther 2024; 31:1107-1120. [PMID: 36927207 DOI: 10.1177/15266028231158302] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
PURPOSE Post-EVAR (endovascular aneurysm repair) aneurysm sac growth can be seen as therapy failure as it is a risk factor for post-EVAR aneurysm rupture. This study sought to identify preoperative patient predictors for developing post-EVAR aneurysm sac growth. MATERIAL AND METHODS A systematic review was conducted to select potential predictive preoperative factors for post-EVAR sac growth (including a total of 34.886 patients), which were evaluated by a retrospective single-center analysis of patients undergoing EVAR between 2009 and 2019 (N=247) with pre-EVAR computed tomography scans and at least 1 year follow-up. The primary study outcome was post-EVAR abdominal aortic aneurysm (AAA) sac enlargement (≥5 mm diameter increase). Multivariate Cox regression and Kaplan-Meier survival curves were constructed. RESULTS Potential correlative factors for post-EVAR sac growth included in the cohort analysis were age, sex, anticoagulants, antiplatelets, renal insufficiency, anemia, low thrombocyte count, pulmonary comorbidities, aneurysm diameter, neck diameter, neck angle, neck length, configuration of intraluminal thrombus, common iliac artery diameter, the number of patent lumbar arteries, and a patent inferior mesenteric artery. Multivariate analysis showed that infrarenal neck angulation (hazard ratio, 1.014; confidence interval (CI), 1.001-1.026; p=0.034) and the number of patent lumbar arteries (hazard ratio, 1.340; CI, 1.131-1.588; p<0.001) were associated with post-EVAR growth. Difference in estimated freedom from post-EVAR sac growth for patients with ≥4 patent lumbar arteries versus <4 patent lumbar arteries became clear after 2 years: 88.5% versus 100%, respectively (p<0.001). Of note, 31% of the patients (n=51) with ≥4 patent lumbar arteries (n=167) developed post-EVAR sac growth. In our cohort, the median maximum AAA diameter was 57 mm (interquartile range [IQR] = 54-62) and the median postoperative follow-up time was 54 months (IQR = 34-79). In all, 23% (n=57) of the patients suffered from post-EVAR growth. The median time for post-EVAR growth was 37 months (IQR = 24-63). In 46 of the 57 post-EVAR growth cases (81%), an endoleak was observed; 2.4% (n=6) of the patients suffered from post-EVAR rupture. The total mortality in the cohort was 24% (n=60); 4% (n=10) was AAA related. CONCLUSIONS This study showed that having 4 or more patent lumbar arteries is an important predictive factor for postoperative sac growth in patients undergoing EVAR. CLINICAL IMPACT This study strongly suggests that having 4 or more patent lumbar arteries should be included in preoperative counseling for EVAR, in conjunction to the instructions for use (IFU).
Collapse
Affiliation(s)
- Laura E Bruijn
- Division of Vascular Surgery, Department of Surgery, Haga Teaching Hospital, The Hague, The Netherlands
- Division of Vascular Surgery, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jihene Louhichi
- Division of Vascular Surgery, Department of Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Hugo T C Veger
- Division of Vascular Surgery, Department of Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Jan J Wever
- Division of Vascular Surgery, Department of Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Lukas C van Dijk
- Division of Interventional Radiology, Department of Radiology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Hendrik van Overhagen
- Division of Interventional Radiology, Department of Radiology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Jaap F Hamming
- Division of Vascular Surgery, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | |
Collapse
|
3
|
Fujitsuna R, Ueda T, Saito H, Matsumoto T, Shirai S, Sugihara F, Hayashi H, Kumita SI. Initial Outcomes of Embolization for Type II Endoleak: Comparison of n-Butyl Cyanoacrylate-Ethiodized Oil Mixture with n-Butyl Cyanoacrylate-Ethiodized Oil-Ethanol Mixture. J Vasc Interv Radiol 2024; 35:1673-1680. [PMID: 39094848 DOI: 10.1016/j.jvir.2024.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 07/04/2024] [Accepted: 07/24/2024] [Indexed: 08/04/2024] Open
Abstract
PURPOSE To compare the safety and effectiveness of n-butyl cyanoacrylate (nBCA)-ethiodized oil (NE) mixture and nBCA-ethiodized oil-ethanol (NEE) mixture embolization for Type II endoleak (T2EL) after endovascular aortic repair. MATERIALS AND METHODS This study included 32 patients with 49 procedures who underwent T2EL embolization between January 2008 and June 2022. Cases with no follow-up after embolization, technical failure, treatment with coil only, Type I endoleak at the embolization, and re-embolization were excluded. The resultant final cohort included 24 patients (14 men and 10 women; mean age, 83.3 years [interquartile range, 77-89 years]) who underwent initial T2EL embolization, with 15 patients in the NE group and 9 patients in the NEE group. The 2 groups were compared in terms of adverse events (AEs), freedom from sac enlargement, and freedom from reintervention. RESULTS The follow-up period after embolization for T2EL was 960 days (SD ± 1,007) in the NE group and 484 days (SD ± 192) in the NEE group, without significant differences. No AEs above moderate were observed in either group. The rate of freedom from sac enlargement at 1 year was 65.0% in the NE group and 87.5% in the NEE group (P = .03). The rate of freedom from reintervention at 1 year was 69.2% in the NE group and 100.0% in the NEE group (P = .02). CONCLUSIONS The NEE group had significantly higher rates of freedom from sac enlargement and reintervention at 1 year compared with the NE group. These results suggest that T2EL embolization with NEE may be more effective than that with NE.
Collapse
Affiliation(s)
- Ryutaro Fujitsuna
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan.
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Hidemasa Saito
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Taiga Matsumoto
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Sayaka Shirai
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Fumie Sugihara
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Hiromitsu Hayashi
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | | |
Collapse
|
4
|
Vaughan-Burleigh S, Leung YYR, Khan F, Lintott P, Howard DPJ. The Safety and Outcomes of Elective Endovascular Aneurysm Repair in the Elderly: A Systemic Review and Meta-Analysis. J Endovasc Ther 2024:15266028241283669. [PMID: 39323301 DOI: 10.1177/15266028241283669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
PURPOSE Prevalence of abdominal aortic aneurysms (AAAs) increases with age. Previous trials confirm that elective endovascular aneurysm repair (EVAR) is an effective intervention for AAA. However, few elderly patients were recruited into randomized trials, whereas in contemporary clinical practice, elective repair is commonly performed on octogenarians. We evaluated the safety and outcome of elective EVAR in elderly patients to inform clinical practice and vascular service provision. METHODS A systematic review and meta-analysis of studies reporting risk of complications and death in patients undergoing elective EVAR was performed (PROSPERO CRD: 42022308423). Observational studies and interventional arms of randomized trials were included if the outcome rates or raw data were provided. Primary outcome was 30-day mortality. Secondary outcomes were longer-term mortality, 30-day major adverse events, and aneurysm-related mortality. Primary and secondary outcomes were compared between octogenarians and non-octogenarians. Exclusion criteria were emergency procedures, non-infrarenal aneurysms, and lack of octogenarian data. RESULTS A total of 41 studies were eligible from 10 099 citations, including 10 national and 5 international registries, 26 retrospective studies, and our own prospective cohort. The analysis included 208 997 non-octogenarians (mean age=70.19 [SD=0.62]) and 106 188 octogenarians (mean age=83.75 [SD=0.35]). The 30-day mortality post-elective EVAR was higher in octogenarians (1.08% in non-octogenarians, 2.31% in octogenarians, odds ratio [OR]=2.27 [2.08-2.47], p<0.0001). Linear regression demonstrated a 0.83% increase in 30-day mortality for every 10-year age increase above 60 years old. Mortality for octogenarians increased significantly during follow-up: 11.35% (OR=1.87 [1.65-2.13], p<0.001), 22.80% (OR=1.89 [1.52-2.35], p<0.001), 32.00% (OR=1.98 [1.66-2.37], p<0.001), 47.53%, and 51.08% (OR=2.40 [1.90-3.03], p<0.001) at 1-through-5-year follow-up, respectively. The 30-day major adverse events after elective EVAR were higher in octogenarians (OR=1.75-2.83, p<0.001). CONCLUSIONS Octogenarians experience higher but acceptable peri-operative morbidity and mortality compared with younger patients. However, 3-year to 5-year survival is very low among octogenarians. Our findings challenge the notion of routine intervention in elderly patients and support very careful selection for elective EVAR. Many octogenarians with peri-threshold (<6 cm) AAAs may derive no benefit from EVAR due to limited 3-year to 5-year overall survival and low risk of aneurysm rupture with conservative management. An adjusted threshold for intervention in octogenarians may be warranted. CLINICAL IMPACT Octogenarians with infra-renal AAA are increasingly managed with elective EVAR. Previous studies have demonstrated that EVAR is safer than open repair for octogenarians, with lower peri-operative mortality and major adverse events. However, randomised trials, on which much of contemporary evidence is based, recruited a relatively younger population of participants. This systematic review and meta-analysis provides a contemporary synthesis of the literature comparing outcomes in octogenarians to younger patients. The results of this analysis, together with low rupture rates amongst octogenarians in existing literature, question the benefit of routine elective intervention for peri-threshold aneurysms and an adjusted threshold for intervention in octogenarians may be warranted.
Collapse
Affiliation(s)
| | - Ya Yuan Rachel Leung
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Faaraz Khan
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Patrick Lintott
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Dominic P J Howard
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| |
Collapse
|
5
|
Becker D, Riggi M, Wyss TR, Jungi S, Weiss S, Kotelis D, Schmidli J, Bosiers MJ, Makaloski V. Indication and Outcome of Late Open Conversion after Abdominal Endovascular Aortic Repair. Ann Vasc Surg 2024; 106:196-204. [PMID: 38810725 DOI: 10.1016/j.avsg.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/20/2024] [Accepted: 02/24/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) has become the standard of care for patients with infrarenal aortic aneurysms over the last 2 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. METHODS This 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. RESULTS During 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). Thirty-day mortality rate was 3% (1/31) with one patient died due to multiorgan 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. CONCLUSIONS Late 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.
Collapse
Affiliation(s)
- Daniel Becker
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Manuela Riggi
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Rudolf Wyss
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Interventional Radiology and Vascular Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Silvan Jungi
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Salome Weiss
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drosos Kotelis
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürg Schmidli
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michel Joseph Bosiers
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
6
|
Torrealba JI, Kölbel T, Rohlffs F, Spanos K, Panuccio G. Branched Endovascular Aortic Repair After a Migrated EVAR Bypassing a Severely Kinked Previous Endograft. J Endovasc Ther 2024; 31:533-540. [PMID: 36342138 DOI: 10.1177/15266028221134888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE To describe a novel technique to repair a juxtarenal abdominal aortic aneurysm (JAAA) after failed endovascular aortic repair (EVAR) with severely kinked anatomy. TECHNIQUE We present a patient who underwent an EVAR with a Medtronic Talent device 15 years ago and a proximal cuff extension 3 years earlier for an abdominal aortic aneurysm. Computed tomography (CT) done for a known gastritis showed a 12 cm JAAA, with a migrated endograft and a type Ia endoleak (EL). Endovascular repair was performed, accessing and navigating the aneurysmal sac outside the previous graft. The type I EL was reached and the suprarenal aorta catheterized. A 4-vessel inner-branched EVAR device was deployed in the distal thoracic aorta and their target vessels bridged through femoral access. A distal bifurcated component was deployed and both iliac limbs were extended to the native distal iliac arteries. Completion angiogram as well as early and 12-month CT showed a fully patent straight course branched EVAR with no ELs. CONCLUSION Complex aortic reinterventions in the presence of previous EVAR can be performed by choosing a straighter course along and parallel to the previous endograft. Several technical aspects must be considered to successfully perform this type of reinterventions. CLINICAL IMPACT We present a technique of a complex endovascular aortic repair in a failed EVAR with kinked anatomy, navigating through the thrombosed aneurysmal sac, outside the previously placed endograft and thus obtaining a straighter path for a new branched endograft. The novelty lies in a different approach to repair a failed EVAR with a branched graft through an uncommon access on the side of the previous endograft, avoiding repeated displacement or occlusion of the new endograft. We exemplify the feasibility of such a complex procedure and highlight important steps to perform it, whether in the abdominal or even thoracic Aorta.
Collapse
Affiliation(s)
| | - Tilo Kölbel
- Universitätsklinikum Hamburg Eppendorf Universitäres Herzzentrum Hamburg GmbH, Hamburg, Germany
| | - Fiona Rohlffs
- Universitätsklinikum Hamburg Eppendorf Universitäres Herzzentrum Hamburg GmbH, Hamburg, Germany
| | - Konstantinos Spanos
- Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Giuseppe Panuccio
- Universitätsklinikum Hamburg Eppendorf Universitäres Herzzentrum Hamburg GmbH, Hamburg, Germany
| |
Collapse
|
7
|
Papadoulas S, Pitros C, Tsimpoukis A, Papageorgopoulou C, Prentza S, Leivaditis V, Antzoulas A, Mulita F, Moulakakis KG. Late post-EVAR abdominal aortic aneurysm rupture: a meta-analysis study. Arch Med Sci Atheroscler Dis 2024; 9:e152-e164. [PMID: 39559174 PMCID: PMC11571202 DOI: 10.5114/amsad/190421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 06/24/2024] [Indexed: 11/20/2024] Open
Abstract
This study presents updated information on post-endovascular aneurysm repair (EVAR) late aortic rupture (LAR) as the data in the literature are limited. It comprises a meta-analysis based on the recent evidence regarding the incidence, causes, treatment outcomes, and prognosis of post-EVAR. A meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were identified by searching electronic databases and scanning bibliographic references from 1991 to April 1, 2023. Our analysis provided evidence that the most common causes of rupture after EVAR were type Ia and Ib Endoleaks (Els). Post-rupture mortality after EVAR was high (35.6%) and comparable to the morbidity of de novo ruptures. Endovascular repair appears to have better results compared to conversion to open repair. A significant number of patients had prior endovascular reoperations and inadequate follow-up. Patient compliance with the surveillance protocol is mandatory.
Collapse
Affiliation(s)
- Spyros Papadoulas
- Department of Vascular Surgery, General University Hospital of Patras, Patras, Greece
| | - Christos Pitros
- Department of Vascular Surgery, General University Hospital of Patras, Patras, Greece
| | - Andreas Tsimpoukis
- Department of Vascular Surgery, General University Hospital of Patras, Patras, Greece
| | | | - Sofia Prentza
- Department of Vascular Surgery, General University Hospital of Patras, Patras, Greece
- Department of Surgery, General University Hospital of Patras, Greece
| | - Vasileios Leivaditis
- Department of Cardiothoracic and Vascular Surgery, WestpfalzKlinikum, Kaiserslautern, Germany
| | - Andreas Antzoulas
- Department of Surgery, General University Hospital of Patras, Greece
| | - Francesk Mulita
- Department of Vascular Surgery, General University Hospital of Patras, Patras, Greece
- Department of Surgery, General University Hospital of Patras, Greece
| | | |
Collapse
|
8
|
Moulakakis KG, Lazaris AM, Georgiadis GS, Kakkos S, Papavasileiou VG, Antonopoulos CN, Papapetrou A, Katsikas V, Klonaris C, Geroulakos G. A Greek Multicentre Study Assessing the Outcome of Late Rupture After Endovascular Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2024; 67:756-764. [PMID: 38154499 DOI: 10.1016/j.ejvs.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 11/02/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Late rupture after endovascular aortic aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) is an increasing complication associated with a high mortality rate. This study aimed to analyse the causes and outcomes in patients with AAA rupture after EVAR. METHODS A multi-institutional Greek study of late ruptures after EVAR between 2008 - 2022 was performed. Primary outcomes were intra-operative and in hospital death. RESULTS A total of 70 patients presented with late rupture after EVAR (proportion of ruptured EVARs among all EVARs, 0.6%; 69 males; mean age 77.2 ± 6.7 years). The mean time interval between EVAR and late rupture was 72.3 months (range 6 - 180 months). In all cases the cause of rupture was the presence of an endoleak (type I, 73%) with sac enlargement. Moreover, 34% of subjects with rupture after EVAR had been lost to follow up and 32% underwent a secondary intervention. Additionally, 57 patients (81%) were treated by conversion to open surgical repair (COSR) and the remainder by endovascular correction of endoleak (ECE). Eleven intra-operative deaths (16%) were recorded. The overall in hospital mortality rate was 41% (23% ECE vs. 46% COSR; p = .21). Of the patients who presented as initially haemodynamically stable, 23% died during hospitalisation, while the respective mortality rate for patients who presented as unstable was 78% (odds ratio [OR] 11.8, 95% confidence interval [CI] 3.6 - 39.1; p < .001). Multivariable logistic regression analysis revealed that severity of haemodynamic shock was the most significant risk factor for intra-operative (OR 7.15, 95% CI 1.58 - 32.40; p = .010) and in hospital death (OR 9.53, 95% CI 2.79 - 32.58; p < .001). CONCLUSION These data underline the devastating prognosis of late rupture after EVAR. Haemodynamic status at presentation was an important predictive factor for death both in the ECE and COSR groups. Rigorous follow up and prompt evaluation of an unstable patient in case of rupture after EVAR is recommended.
Collapse
Affiliation(s)
- Konstantinos G Moulakakis
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, University of Patras Medical School, Patras, Greece.
| | - Andreas M Lazaris
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Stavros Kakkos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | | | - Constantine N Antonopoulos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasios Papapetrou
- Hellenic Vascular Registry (HEVAR); Vascular Surgery Clinic, K.A.T. General Hospital, Athens, Greece
| | - Vasilios Katsikas
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Gennimatas General Hospital of Athens, Athens, Greece
| | - Chris Klonaris
- Hellenic Vascular Registry (HEVAR); 2nd Department of Vascular Surgery, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - George Geroulakos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
9
|
Roditis K, Tsiantoula P, Giannakopoulos NN, Antoniou A, Papaioannou V, Tzamtzidou S, Manou D, Seretis KG, Papas TT, Bessias N. Laparoscopic Ligation of the Inferior Mesenteric Artery: A Systematic Review of an Emerging Trend for Addressing Type II Endoleak Following Endovascular Aortic Aneurysm Repair. J Clin Med 2024; 13:2584. [PMID: 38731113 PMCID: PMC11084248 DOI: 10.3390/jcm13092584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/21/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024] Open
Abstract
Background/Objectives: this systematic review aims to explore the efficacy and safety of the laparoscopic ligation of the inferior mesenteric artery (IMA) as an emerging trend for addressing a type II endoleak following endovascular aortic aneurysm repair (EVAR). Methods: A comprehensive literature search was conducted across several databases including Medline, Scopus, and the Cochrane Central Register of Controlled Trials, adhering to the PRISMA guidelines. The search focused on articles reporting on the laparoscopic ligation of the IMA for the treatment of a type II endoleak post-EVAR. Data were extracted regarding study characteristics, patient demographics, technical success rates, postoperative outcomes, and follow-up results. Results: Our analysis included ten case studies and two retrospective cohort studies, comprising a total of 26 patients who underwent a laparoscopic ligation of the IMA between 2000 and 2023. The mean age of the cohort was 72.3 years, with a male predominance (92.3%). The mean AAA diameter at the time of intervention was 69.7 mm. The technique demonstrated a high technical success rate of 92.3%, with a mean procedure time of 118.4 min and minimal blood loss. The average follow-up duration was 19.9 months, with 73% of patients experiencing regression of the aneurysmal sac, and no reports of an IMA-related type II endoleak during the follow-up period. Conclusions: The laparoscopic ligation of the IMA for a type II endoleak following EVAR presents a promising, minimally invasive alternative with high technical success rates and favorable postoperative outcomes. Despite its potential advantages, including reduced contrast agent use and radiation exposure, its application remains limited to specialized centers. The findings suggest the need for further research in larger prospective studies to validate the effectiveness of this procedure and potentially broaden its clinical adoption.
Collapse
Affiliation(s)
- Konstantinos Roditis
- Department of Vascular Surgery, Korgialenio-Benakio Hellenic Red Cross Hospital, 115 26 Athens, Greece; (P.T.); (N.-N.G.); (A.A.); (V.P.); (S.T.); (D.M.); (K.G.S.); (T.T.P.); (N.B.)
| | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Haidar H, Kapahnke S, Frese JP, Omran S, Mueller V, Hinterseher I, Sommerfeld M, Kaschina E, Konietschke F, Greiner A, Buerger M. Risk factors for elective and urgent open conversion after EVAR-a retrospective observational study. Vascular 2024; 32:243-253. [PMID: 36413465 PMCID: PMC11129523 DOI: 10.1177/17085381221141118] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) has become the standard procedure for treating infrarenal abdominal aortic aneurysms (AAA). Various associated complications can lead to open conversion (OC). Thorough follow-up after the procedure is mandatory for the early detection of complications. Persisting perfusion of the aneurysm, a so-called endoleak (EL), paired with structural instability because of aortic wall atrophy and impaired cell functionality induced by EVAR, results in a high risk for aortic rupture. PURPOSE The goal of this study was to detect the risk factors for elective and urgent OC as a result of EVAR-induced pathophysiological changes inside the aortic wall. RESEARCH DESIGN Retrospective data analysis was performed on all open aortic repairs from January 2016 to December 2020. DATA COLLECTION AND ANALYSIS Fifty patients were identified as treated by OC for failure of an infrarenal EVAR. The patients were divided into two subgroups, here depending on the urgency of surgery. Statistical analysis of patient characteristics and outcomes was performed. RESULTS The most common indications for OC were various types of EL (74%), resulting in an aortic rupture in 15 patients. Patients with insufficient or absent follow-up were treated more frequently in an emergency setting (16% vs. 63%). The mortality rate was higher in cases of emergency OC (3% vs. 26%). CONCLUSIONS Particularly in cases of insufficient or absent follow-up, complications such as EL pose an enormous risk for fatal aortic rupture.
Collapse
Affiliation(s)
- Haidar Haidar
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Sebastian Kapahnke
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Jan P Frese
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Safwan Omran
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Verena Mueller
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Irene Hinterseher
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Germany
| | - Manuela Sommerfeld
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pharmacology, Center for Cardiovascular Research (CCR), Berlin, Germany
| | - Elena Kaschina
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pharmacology, Center for Cardiovascular Research (CCR), Berlin, Germany
| | - Frank Konietschke
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, Institute of Medical Biometrics and Clinical Epidemiology and Berlin Institute of Health (BIH), Berlin, Germany
| | - Andreas Greiner
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Matthias Buerger
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| |
Collapse
|
11
|
Rakemaa L, Aho PS, Tulamo R, Laine MT, Laukontaus SJ, Hakovirta H, Venermo M. Ultrasound Surveillance is Feasible After Endovascular Aneurysm Repair. Ann Vasc Surg 2024; 100:223-232. [PMID: 37926137 DOI: 10.1016/j.avsg.2023.09.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/05/2023] [Accepted: 09/09/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Surveillance after endovascular aneurysm repair (EVAR) is traditionally done with computed tomography angiography (CTA) scans that exposes patient to radiation, nephrotoxic contrast media, and potentially increased risk for cancer. Ultrasound (US) is less labor intensive and expensive and might thus provide a good alternative for CTA surveillance. The aim of this study was to evaluate in real-life patient cohorts whether US is able to detect post-EVAR aneurysm-related complications similarly to CTA. METHODS This retrospective study compared the outcome of consecutive patients who underwent EVAR for intact abdominal aortic aneurysm and were surveilled solely by CTA (CTA-only cohort, n = 168) in 2000-2010 or by combined CTA and US (CTA/US cohort, n = 300) in 2011-2016, as a standard surveillance protocol in the department of vascular surgery, Helsinki University Hospital. The CTA-only patients were imaged at 1, 3, and 12 months and annually thereafter. The CTA/US patients were imaged with CTA at 3 and 12 months, US at 6 months and annually thereafter. If there were suspicion of >5 mm aneurysm growth, CTA scan was performed. The patients were reviewed for imaging data, reinterventions, aneurysm ruptures, and death until December 2018. The 2 groups were compared for secondary rupture, aneurysm-related and cancer-related death, reintervention related to abdominal aortic aneurysm, and maximum aneurysm diameter increase ≥5 mm. The mean follow-up in the CTA-only cohort was 67 months and in CTA/US cohort 43 months. RESULTS The 2 cohorts were alike for basic characteristics and for the mean aneurysm diameter. The total number of CT scans for detecting aneurysm was 84.1/100 patient years in the CTA-only cohort compared to 74.5/100 patient years for US/CTA cohort. Forty percent of patients under combined CTA/US surveillance received 1 or more additional CTA scans. The 2 cohorts did not differ for 1-year, 5-year and 8-year freedom from aneurysm related death, secondary sac rupture, nor the incidence of rupture preventing interventions. CONCLUSIONS Based on the follow-up data of this real-life cohort of 468 patients, combined surveillance with US and additional CTA either per protocol or due to suspicion of aneurysm-related complications had comparable outcome with sole CTA-surveillance. Thus, US can be considered a reasonable alternative for the CTA. However, our study showed also that the need of additional CTAs due to suspicion of endoleak or aneurysm nonrelated reasons is substantial.
Collapse
Affiliation(s)
- Lotta Rakemaa
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Pekka S Aho
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Riikka Tulamo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Matti T Laine
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Sani J Laukontaus
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Harri Hakovirta
- Department of Vascular Surgery, University of Turku and Turku University Hospital, Turku, Varsinais-Suomi, Finland; Department of Surgery, Satasairaala Hospital, Pori, Satakunta, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland.
| |
Collapse
|
12
|
Chun JY, de Haan M, Maleux G, Osman A, Cannavale A, Morgan R. CIRSE Standards of Practice on Management of Endoleaks Following Endovascular Aneurysm Repair. Cardiovasc Intervent Radiol 2024; 47:161-176. [PMID: 38216742 PMCID: PMC10844414 DOI: 10.1007/s00270-023-03629-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/19/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Endoleaks represent the most common complication after EVAR. Some types are associated with ongoing risk of aneurysm rupture and necessitate long-term surveillance and secondary interventions. PURPOSE This document, as with all CIRSE Standards of Practice documents, will recommend a reasonable approach to best practices of managing endoleaks. This will include imaging diagnosis, surveillance, indications for intervention, endovascular treatments and their outcomes. Our purpose is to provide recommendations based on up-to-date evidence, updating the guidelines previously published on this topic in 2013. METHODS The writing group was established by the CIRSE Standards of Practice Committee and consisted of clinicians with internationally recognised expertise in endoleak management. The writing group reviewed the existing literature performing a pragmatic evidence search using PubMed to select publications in English and relating to human subjects up to 2023. The final recommendations were formulated through consensus. RESULTS Endoleaks may compromise durability of the aortic repair, and long-term imaging surveillance is necessary for early detection and correct classification to guide potential re-intervention. The majority of endoleaks that require treatment can be managed using endovascular techniques. This Standards of Practice document provides up-to-date recommendations for the safe management of endoleaks.
Collapse
Affiliation(s)
- Joo-Young Chun
- St George's University Hospitals NHS Foundation Trust, London, UK.
- St George's University of London, London, UK.
| | - Michiel de Haan
- Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Asaad Osman
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Robert Morgan
- St George's University Hospitals NHS Foundation Trust, London, UK
- St George's University of London, London, UK
| |
Collapse
|
13
|
Özdemir-van Brunschot DMD, Tevs M, Holzhey D. Results of the Chimney Technique in a Community Hospital. Vasc Endovascular Surg 2024; 58:20-28. [PMID: 37349149 DOI: 10.1177/15385744231185640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND The chimney technique, fenestrated or branched endovascular aortic repair are endovascular options in patients with a juxtarenal, suprarenal or type IV thoraco-abdominal aneurysm. The chimney technique has specific advantages and disadvantages. A retrospective single center study was performed to describe the results. PATIENTS AND METHODS All consecutive patients in whom the chimney technique was used between 1th January 2011 and 31th December 2020 were included. We excluded patients who needed a revision of an existing EVAR and patients with a para-anastomotic aneurysm. Outcomes were reported in accordance with the reporting standards. RESULTS 38 Patients were included in the study, a total of 59 chimney grafts were deployed. At a median follow-up duration of 26.6 months, there were 9 patients with occlusion of the chimney graft. In 1 patient an iliac renal bypass was performed. In the other patients the renal function stabilized and no further therapy was necessary. All chimneys in the mesenteric arteries remained patent. Gutter endoleak was seen in 5 patients, 3 patients were successfully treated and in the other 2 patients the gutter endoleak disappeared spontaneously. CONCLUSIONS Conclusions should be drawn carefully as this is a retrospective non-comparative study. Results from 38 patients treated with the chimney technique are presented. Chimney graft occlusion rate was 15.3% at the end of follow-up. However, the majority (77.8%) of the occluded stents were self-expandable stents, stressing the importance of selecting the right devices.
Collapse
Affiliation(s)
- Denise M D Özdemir-van Brunschot
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group Düsseldorf, Düsseldorf, Germany
- Faculty of Health, University Witten/Herdecke, Witten, Germany
| | - Maria Tevs
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group Düsseldorf, Düsseldorf, Germany
| | - David Holzhey
- Faculty of Health, University Witten/Herdecke, Witten, Germany
- Department of Cardiac Surgery, Helios University Hospital Wuppertal, Wuppertal, Germany
| |
Collapse
|
14
|
Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | | |
Collapse
|
15
|
Radtka JF, Zil-E-Ali A, Medina D, Aziz F. Patients from distressed communities are more likely to be symptomatic at endovascular aneurysm repair and have an increased risk of being lost to long-term follow-up. J Vasc Surg 2023; 77:1087-1098.e3. [PMID: 36343872 DOI: 10.1016/j.jvs.2022.10.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/17/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) has become the preferred modality to repair abdominal aortic aneurysms (AAAs). However, the effect of the distressed communities index (DCI) on the outcomes of EVAR is still unknown. In the present study, we investigated the effect of DCI on the postoperative outcomes after EVAR. METHODS The Society for Vascular Surgery Vascular Quality Initiative database was used for the present study. Patients who had undergone EVAR from 2003 to 2021 were selected for analysis. The study cohort was divided into two groups according to their DCI score. Patients with DCI scores ranging from 61 to 100 were assigned to group I (DCI >60), and those with DCI scores ranging from 0 to 60 were assigned to group II (DCI ≤60). The primary outcomes included the 30-day and 1-year mortality and major adverse cardiovascular events at 30 days. Regression analyses were performed to study the postoperative outcomes. P values ≤ .05 were deemed statistically significant for all analyses in the present study. RESULTS A total of 60,972 patients (19.5% female; 80.5% male) had undergone EVAR from 2003 to 2021. Of these patients, 18,549 were in group I (30.4%) and 42,423 in group II (69.6%). The mean age of the study cohort was 73 ± 8.9 years. Group I tended to be younger (mean age, 72.6 vs 73.7 years), underweight (3.5% vs 2.5%), and African American (10.8% vs 3.5%) and were more likely to have Medicaid insurance (3.6% vs 1.9%; P < .05 for all). Group I had had more smokers (87.3% vs 85.3%), a higher rate of comorbidities, including hypertension (84.5% vs 82.9%), diabetes (21.7% vs 19.7%), coronary artery disease (30.3% vs 28.6%), chronic obstructive pulmonary disease (36.9% vs 31.8%), and moderate to severe congestive heart failure (2.6% vs 2%; P < .05 for all). The group I patients were more likely to undergo EVAR for symptomatic AAAs (11.1% vs 7.9%; P < .001; adjusted odds ratio [aOR], 1.25; 95% confidence interval [CI], 1.15-1.37; P < .001) with a higher risk of mortality at 30 days (aOR, 3.98; 95% CI, 2.23-5.44; P < .001) and 1 year (aOR, 1.74; 95% CI, 1.43-2.13; P < .001). A higher risk of being lost to follow-up (28.9% vs 26.3%; P < .001) was also observed in group I. CONCLUSIONS Patients from distressed communities who require EVAR tended to have multiple comorbidities. These patients were also more likely to be treated for symptomatic AAAs, with a higher risk of mortality. An increased incidence of lost to long-term follow-up was also observed for this population. Surgeons and healthcare systems should consider these outcomes and institute patient-centered approaches to ensure equitable healthcare.
Collapse
Affiliation(s)
- John F Radtka
- Division of Vascular Surgery, Pennsylvania State University College of Medicine, Hershey, PA
| | - Ahsan Zil-E-Ali
- Division of Vascular Surgery, Pennsylvania State University College of Medicine, Hershey, PA.
| | - Daniela Medina
- Office of Medical Education, Pennsylvania State University College of Medicine, Hershey, PA
| | - Faisal Aziz
- Division of Vascular Surgery, Pennsylvania State University College of Medicine, Hershey, PA
| |
Collapse
|
16
|
Ozawa H, Ohki T, Shukuzawa K, Chono Y, Omori M, Baba T, Hara M, Tachihara H. Evolution of open aneurysmorrhaphy for management of sac expansion after endovascular repair of abdominal aortic aneurysms. J Vasc Surg 2023; 77:760-768. [PMID: 36306936 DOI: 10.1016/j.jvs.2022.10.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE We evaluated the perioperative and mid-term clinical outcomes of open aneurysmorrhaphy (OA) for the treatment of sac expansion after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms. METHODS OA involves sac exposure without dissection of the proximal or distal neck, sacotomy and ligation of back-bleeding vessels, preservation of the prior stent graft, and tight closure of the sac around the stent graft. We performed a retrospective review of all patients who had undergone OA for nonruptured sac expansion after standard EVAR at our institution between January 2015 and June 2021. The primary end points were 30-day mortality and aneurysm-related death. The secondary end points were postoperative complications, overall survival, freedom from reintervention, and sac regrowth rate. RESULTS A total of 28 patients had undergone OA. Their mean age was 76.9 ± 6.7 years. The median sac diameter at OA was 79 mm (interquartile range [IQR], 76-92 mm). The median duration from the index EVAR to OA was 82 months (IQR, 72-104 months). Preoperative computed tomography angiography confirmed a type II endoleak (EL) in 20 patients, 1 of whom had had a coexisting type Ia EL; a type IIIb EL was identified in 1 patient. Concomitant endovascular procedures had been performed in six patients to treat a type I or III EL or reinforce the proximal and distal seals. The OA technique has been modified since 2017, with the addition of more aggressive dissection of the sac and complete removal of the mural thrombus to further decrease the sac diameter. Postoperative complications occurred in two patients and included abdominal lymphorrhea and failed hemostasis of the common femoral artery requiring surgical repair in one patient each. The 30-day mortality was 0%. During the median follow-up of 36 months (IQR, 14-51 months), the overall survival was 92.7% and 86.9% at 12 and 36 months, respectively, without any aneurysm-related death. In the late (2017-2021) treatment group, the median sac diameter immediately after OA was smaller than that in the early (2015-2016) treatment group (early group: median, 50 mm; IQR, 39-57 mm; vs later group: median, 41 mm; IQR, 32-47 mm; P = .083). Furthermore, in the late group, the sac regrowth rate was lower (early group: median, 0.36 mm/mo; IQR, 0.23-0.83 mm/mo; vs late group: median, 0 mm/mo; IQR, 0-0.11 mm/mo; P = .0075) and the freedom from reintervention rate was higher (late group: 94.7% at both 12 and 36 months, respectively; early group: 71.4% and 53.6% at 12 and 36 months, respectively; log-rank P = .070). CONCLUSIONS Our results have shown that OA for the management of post-EVAR sac expansion is feasible with acceptable mid-term outcomes. Aggressive dissection and tight plication of the sac might be imperative for better mid-term outcomes after OA.
Collapse
Affiliation(s)
- Hirotsugu Ozawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Kota Shukuzawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiko Chono
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Makiko Omori
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takeshi Baba
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masayuki Hara
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiromasa Tachihara
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
17
|
Salvi C, Besancenot A, Sebahi S, Rinckenbach S, Salomon Du Mont L. Influence of Home Location on Follow-Up Compliance after Endovascular Treatment for Abdominal Aortic Aneurysm. Ann Vasc Surg 2023:S0890-5096(23)00001-8. [PMID: 36641089 DOI: 10.1016/j.avsg.2022.10.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND The complications of EVAR require compliance to a close follow-up imaging. The purpose of this study was to determine whether home location predicted a poor compliance to imaging follow-up after EVAR. METHODS We analyzed a cohort of patients treated by EVAR at the Besançon University Hospital between 2007 and 2017. Follow-up imaging followed the French High Health Authority recommendations. Noncompliance with follow-up compliance was defined as a first missed postoperative appointment or 2 consecutive missed appointments after the first control CT-scan, and 2 groups of patients were identified: compliant (group C) or noncompliant (group NC). Univariate and multivariate analyzes were used to investigate compliance risk factors. Collected complications included endoleaks, limb thrombosis, infections, and secondary ruptures. RESULTS Two hundred and fifty-eight of the 359 patients treated during this period were enrolled, including 233 men (90.3%), with a mean age of 74.0 years (±9.0) and a mean follow-up of 5.0 years (±2.6). The compliance rate was 38.8% and the 1-year mortality rate was 12.0%. Using univariate and multivariate analysis, a place of residence greater located over 60 min away from the hospital had a poor effect on compliance (Odd ratio [OR] = 0.58; P = 0.047). Peripheral arterial occlusive disease (PAD) and an abdominal aortic aneurysm (AAA) diameter greater than 5.0 cm were protective factors (OR = 2.23; P = 0.006 and OR = 1.85, respectively; P = 0.002). Four-year all-cause mortality was 21.0% in group C and 17.0% in the NC group (P = 0.54). Complications were more significant in group C (59.0%) compared to group NC (39.0%) (P = 0.001). Two ruptures occurred in the NC group (1.3%), versus none in the C group (P = 0.25). CONCLUSIONS In this study, a long distance from the home to the hospital was a detrimental factor for follow up compliance. However, a good compliance did not decrease the 4-year mortality rate. The high rate of noncompliance found should lead to a more personalized follow-up strategy taking into account the anatomical elements but also the comorbidities and some social aspects.
Collapse
Affiliation(s)
- Charlène Salvi
- University Hospital, Vascular Surgery Unit, Besançon, France.
| | | | - Soumia Sebahi
- University Hospital, Vascular Surgery Unit, Besançon, France
| | - Simon Rinckenbach
- University Hospital, Vascular Surgery Unit, Besançon, France; University of Franche Comté, Besançon, France
| | - Lucie Salomon Du Mont
- University Hospital, Vascular Surgery Unit, Besançon, France; University of Franche Comté, Besançon, France
| |
Collapse
|
18
|
Shen Y, Wang J, Zhao J, Yuan D, Wang T, Huang B. DANCER: Study protocol of a prospective, non-randomized controlled trial for crossed limb versus standard limb configuration in endovascular abdominal aortic aneurysm repair. Front Cardiovasc Med 2022; 9:1046200. [DOI: 10.3389/fcvm.2022.1046200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/27/2022] [Indexed: 11/10/2022] Open
Abstract
BackgroundHostile anatomy, especially severely angulated neck and tortuous iliac arteries, has always been a conundrum in endovascular aneurysm repair (EVAR). Crossed limb (CL) graft, also called the “ballerina technique,” has been utilized to address this problem by facilitating gate cannulation. In terms of short and long-term outcomes, correlated studies have made inconsistent conclusions and this issue remains controversial. Based on a previous cohort study conducted in our center, we aim to prospectively compare the safety and efficacy between CL and standard limb (SL) configuration in patients receiving EVAR.MethodsThis is a prospective, single-center, non-randomized controlled trial. A total of 275 patients who meet the inclusion criteria will be enrolled and allocated with a 4:11 ratio of CL to SL, which is based on results of our previous study. All patients will receive same perioperative management and postoperative medications. All EVAR procedures will be performed under standard protocol, utilizing Endurant II or IIs Stent Graft. The configuration of the graft stent will be decided by surgeons and confirmed by final angiography. The primary outcome is 3-year freedom from major adverse limb-graft events (MALEs). Endpoints will be assessed at the following time points: 1, 6, 12, 24, and 36 months.DiscussionTo our best knowledge, this crosseD vs. stANdard Configuration in Endovascular Repair (DANCER) trial is the first non-randomized controlled trial to compare these two graft configurations in EVAR. The main aim is to compare the MALEs between two groups at 3 years postoperatively. This trial will hopefully provide high-level evidence for employing CL in EVAR.Clinical trial registration[www.chictr.org.cn], identifier [ChiCTR2100053055].
Collapse
|
19
|
Andersson M, Sandström C, Stackelberg O, Lundqvist R, Nordanstig J, Jonsson M, Roy J, Andersson M, Hultgren R, Roos H. Editor's Choice - Structured Computed Tomography Analysis can Identify the Majority of Patients at Risk of Post-Endovascular Aortic Repair Rupture. Eur J Vasc Endovasc Surg 2022; 64:166-174. [PMID: 35561947 DOI: 10.1016/j.ejvs.2022.04.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 04/13/2022] [Accepted: 04/30/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The main objective was to report mechanisms and precursors for post-endovascular aneurysm repair (EVAR) rupture. The second was to apply a structured protocol to explore whether these factors were identifiable on follow up computed tomography (CT) prior to rupture. The third objective was to study the incidence, treatment, and outcome of post-EVAR rupture. METHODS This was a multicentre, retrospective study of patients treated with standard EVAR at five Swedish hospitals from 2008 to 2018. Patients were identified from the Swedvasc registry. Medical records were reviewed up to 2020. Index EVAR and follow up data were recorded. The primary endpoint was post-EVAR rupture. CT at follow up and at post-EVAR rupture were studied, using a structured protocol, to determine rupture mechanisms and identifiable precursors. RESULTS In 1 805 patients treated by EVAR, 45 post-EVAR ruptures occurred in 43 patients. The cumulative incidence was 2.5% over a mean follow up of 5.2 years. The incidence rate was 4.5/1 000 person years. Median time to post-EVAR rupture was 4.1 years. A further six cases of post-EVAR rupture in five patients found outside the main cohort were included in the analysis of rupture mechanisms only. The rupture mechanism was type IA in 20 of 51 cases (39%), IB in 20 of 51 (39%) and IIIA/B in 11 of 51 (22%). One of these had type IA + IB combined. One patient had an aortoduodenal fistula without another mechanism being identified. Precursors had been noted on CT follow up prior to post-EVAR rupture in 16 of 51 (31%). Retrospectively, using the structured protocol, precursors could be identified in 43 of 51 (84%). In 17 of 27 (63%) cases missed on follow up but retrospectively identifiable, the mechanisms were type IB/III. Overall, the 30 day mortality rate after post-EVAR rupture was 47% (n = 24/51) and the post-operative mortality rate was 21% (n = 7/33). CONCLUSIONS Most precursors of post-EVAR rupture are underdiagnosed but identifiable before rupture using a structured follow up CT protocol. Precursors of type IB and III failures caused the majority of post-EVAR ruptures.
Collapse
Affiliation(s)
- Mattias Andersson
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sunderbyn Hospital, Sunderbyn, Sweden
| | - Charlotte Sandström
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Otto Stackelberg
- Section of Vascular Surgery, Department of Clinical Science and Education, Karolinska Institutet at Södersjukhuset, Stockholm, Sweden; Institute of Environmental Medicine, Unit of Cardiovascular and Nutritional Epidemiology, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Robert Lundqvist
- Department of Public Health and Clinical Medicine, Umeå University, Norrbotten County Council, Umeå, Sweden
| | - Joakim Nordanstig
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Jonsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Manne Andersson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Surgery, Ryhov Hospital, Jönköping, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Håkan Roos
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Ryhov Hospital, Jönköping, Sweden.
| |
Collapse
|
20
|
Steadman JA, Moynagh MR, Oderich GS, Mendes BC. Effective treatment of type IIb endoleak via targeted translumbar embolization. J Vasc Surg Cases Innov Tech 2022; 8:232-236. [PMID: 35493344 PMCID: PMC9046119 DOI: 10.1016/j.jvscit.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 03/03/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
| | | | - Gustavo S. Oderich
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Bernardo C. Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
- Correspondence: Bernardo C. Mendes, MD, Gonda Vascular Center, 200 First St SW, 55905, Rochester, MN 55905
| |
Collapse
|
21
|
De Guerre LEVM, O'Donnell TFX, Varkevisser RRB, Swerdlow NJ, Li C, Dansey K, van Herwaarden JA, Schermerhorn ML, Patel VI. The Association between Device Instructions for Use Adherence and Outcomes after Elective Endovascular Aortic Abdominal Aneurysm Repair. J Vasc Surg 2022; 76:690-698.e2. [PMID: 35276256 DOI: 10.1016/j.jvs.2022.02.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/14/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Aortic neck anatomy has a significant impact on the complexity of endovascular aortic aneurysm repair (EVAR), with concern that neck characteristics outside of instructions for use (IFU) may result in worse outcomes. Therefore, this study determined the impact of neck characteristics outside of IFU on perioperative and one-year outcomes and mid-term survival after EVAR. METHODS We identified all patients undergoing elective infrarenal EVAR from December 2014 to May 2020 in the Vascular Quality Initiative database. Neck characteristics outside of IFU were determined based the specific device IFU neck characteristics (Neck diameter, length, and angulation). Patients without one-year follow-up were excluded for the 1-year outcomes analyses (n=6,138 (40%)). We used multivariable adjusted logistic regression and Cox proportional hazard models to identify the independent associations between neck characteristics outside of IFU and our outcomes. RESULTS Of the 15,448 patients identified, 22.1% had neck characteristics outside of IFU, including 6.6% with a infrarenal angle, 6.8% with a neck length, 10.4% with a neck diameter, and 1.1% with a suprarenal angulation outside of IFU. Of these, 2.4% had more than one neck characteristic outside of IFU. Patients with neck characteristics outside of IFU were more often female (27.9% vs. 15.0%, P<.001) and were older (median age 75 vs. 73, P<.001). EVAR patients with neck characteristics outside of IFU had higher rates of type Ia endoleaks at completion (4.8% vs. 2.5%, P<.001), perioperative mortality (1.2% vs. 0.6%, P<.001), one-year sac expansion (7.1% vs. 5.3%, P=.017), and one-year reinterventions (4.4% vs. 3.2%, P=.03). In multivariable adjusted analyses, neck characteristics outside of IFU were independently associated with type Ia completion endoleaks (OR 1.6, [1.3-2.0], P<.001), perioperative mortality (OR 1.8; [1.2-2.7]; P=.005), one-year sac expansion (OR 1.4; [1.0-1.8]; P=.025) and one-year reinterventions (OR 1.4; [1.0-1.9]; P=.039). Unadjusted mid-term survival was lower for patients with neck characteristics outside of IFU than for patients without (5-year survival 84.0% vs. 86.7%, log-rank<.001). However, after adjustment, survival was similar for patients with neck characteristics outside of IFU to those within (HR: 1.1; [1.0-1.3]; P=.22). CONCLUSION Neck characteristics outside of IFU are independently associated with completion type Ia endoleaks, perioperative mortality, one-year sac expansion and one-year reinterventions among patients undergoing elective EVAR. These results indicate that continued effort is needed to improve the proximal seal in patients with neck characteristics outside of IFU undergoing EVAR. Also, in patients with severe hostile neck characteristics, alternative approaches such as open repair, use of a fenestrated or branched device, or endoanchors should be considered.
Collapse
Affiliation(s)
- Livia E V M De Guerre
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Thomas F X O'Donnell
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Rens R B Varkevisser
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Nicholas J Swerdlow
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Chun Li
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kirsten Dansey
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Marc L Schermerhorn
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Virendra I Patel
- Division of Vascular and Endovascular Surgery, New York Presbyterian/Columbia University Irving Medical Center/ Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032.
| |
Collapse
|
22
|
Cost effectiveness of computed tomography versus ultrasound-based surveillance following endovascular aortic repair of intact infrarenal abdominal aortic aneurysms. J Vasc Surg 2022; 76:707-713.e1. [DOI: 10.1016/j.jvs.2022.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/28/2022] [Indexed: 11/22/2022]
|
23
|
Sirignano P, Mangialardi N, Nespola M, Aloisi F, Orrico M, Ronchey S, Del Porto F, Taurino M. Incidence and Fate of Refractory Type II Endoleak after EVAR: A Retrospective Experience of Two High-Volume Italian Centers. J Pers Med 2022; 12:339. [PMID: 35330339 PMCID: PMC8954032 DOI: 10.3390/jpm12030339] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: The aim of the present study is to report the outcome of patients presenting an isolated type II endoleak (TIIEL) requiring reintervention and to identify clinical and anatomical characteristics potentially implicated in refractory TIIEL occurrence and fate. Materials and Methods: A multicenter retrospective study on TIIEL requiring reintervention was conducted between January 2003 and December 2020. Demographic and clinical characteristics, procedural technical aspects, reinterventions, and outcomes were recorded. TIIEL determining sac expansion greater than 10 mm underwent a further endovascular procedure aiming to exclude aneurismal sac. Redo endovascular procedures were performed via endoleak nidus direct embolization and/or aortic side branches occlusion. TIIELs responsible for persisting aneurysmal sac perfusion 6 months after redo endovascular procedures were classified as “refractory” and submitted to open conversion. Results: A total of 102 TIIEL requiring reintervention were included in the final analysis. Eighty-eight (86.27%) patients were male, the mean age was 77.32 ± 8.08 years, and in 72.55% of cases the American Society of Anaesthesiologists (ASA) class was ≥3. The mean aortic diameter was 64.7 ± 14.02 mm, half of treated patients had a patent inferior mesenteric artery (IMA), and 44.11% ≥ 3 couples of patent lumbar arteries (LA). In 49 cases (48.03%) standard endovascular aneurysm repair (EVAR) procedure was completed without adjunctive maneuvers. All enrolled patients were initially submitted to a further endovascular procedure once TIIEL requiring reintervention was diagnosed; 57 patients underwent LAs or IMA embolization (55.87%), 42 transarterial aneurismal sac embolization (41.17%), and three (2.96%) laparoscopic ostial ligations of the inferior mesenteric artery. During a mean follow-up of 15.22 ± 7.57 months (7−48), a redo endovascular approach was able to ensure complete sac exclusion in 52 cases, while 50 patients presented a still evident refractory TIIEL and therefore a surgical conversion or semiconversion was conducted. At the univariate analysis refractory TIIEL patients were significantly different from those who did not develop the complication in terms of preoperative clinical, morphological characteristics, and initial EVAR procedures: coronary artery disease occurrence (p = 0.005, OR: 3.18, CI95%: 1.3−7.2); preoperative abdominal aortic aneurysm (AAA) sac diameter (p = 0.0055); IMA patency (p = 0.016, OR: 2.64, CI95%: 1.18−5.90); three or more patent LAs; isolated standard EVAR without adjunctive procedures (p > 0.0001; OR: 9.48, CI95%: 3.84−23.4). Conclusions: Our experience seems to demonstrate that it is reasonable to try to preoperatively identify those patients who will develop a refractory TIIEL after EVAR and those with a TIIEL requiring reintervention for whom a simple endovascular redo will not be enough, needing surgical conversion.
Collapse
Affiliation(s)
- Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Sant’Andrea Hospital, Department of Surgery Paride Stefanini, Sapienza University of Rome, 00189 Rome, Italy
| | - Nicola Mangialardi
- Department of Vascular Surgery, Ospedale San Camillo-Forlanini, 00152 Rome, Italy; (N.M.); (M.O.); (S.R.)
| | - Martina Nespola
- Vascular and Endovascular Surgery Unit, Sant’Andrea Hospital, Department of Molecular and Clinical Medicine, Sapienza University of Rome, 00189 Rome, Italy; (M.N.); (F.A.); (M.T.)
| | - Francesco Aloisi
- Vascular and Endovascular Surgery Unit, Sant’Andrea Hospital, Department of Molecular and Clinical Medicine, Sapienza University of Rome, 00189 Rome, Italy; (M.N.); (F.A.); (M.T.)
| | - Matteo Orrico
- Department of Vascular Surgery, Ospedale San Camillo-Forlanini, 00152 Rome, Italy; (N.M.); (M.O.); (S.R.)
| | - Sonia Ronchey
- Department of Vascular Surgery, Ospedale San Camillo-Forlanini, 00152 Rome, Italy; (N.M.); (M.O.); (S.R.)
| | - Flavia Del Porto
- Internal Medicine Unit, Sant’Andrea Hospital, Department of Molecular and Clinical Medicine, Sapienza University of Rome, 00189 Rome, Italy;
| | - Maurizio Taurino
- Vascular and Endovascular Surgery Unit, Sant’Andrea Hospital, Department of Molecular and Clinical Medicine, Sapienza University of Rome, 00189 Rome, Italy; (M.N.); (F.A.); (M.T.)
| |
Collapse
|
24
|
Xie X, Shu X, Zhang W, Guo D, Zhang WW, Wang L, Fu W. A Comparison of Clinical Outcomes of Endovascular Repair Versus Open Surgery for Ruptured Descending Thoracic Aorta. J Endovasc Ther 2021; 29:307-318. [PMID: 34779300 DOI: 10.1177/15266028211057087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The comparisons between thoracic endovascular aortic repair for ruptured thoracic aorta (TEVAR) and open surgery (OS) have not been well documented, although both procedures have been widely utilized. We performed a systematic review and meta-analysis to investigate the effectiveness and safety between TEVAR and OS in the repair of ruptured descending thoracic aorta. METHODS PubMed, Embase, and Cochrane Library databases were searched to find relevant studies to assess TEVAR and OS outcomes. The comparative parameters were perioperative mortality (30 day/in-hospital), 1 year mortality, paraplegia or paraparesis, renal insufficiency, stroke, pulmonary embolism, re-intervention rate, pulmonary complications, and cardiac complications. A fixed-effects model was applied to calculate the odds ratio (OR) with a 95% confidence interval (CI) on pooled outcomes from different studies. RESULTS Eighteen observational trials involving 2088 patients were evaluated (TEVAR=560; OS=1528). Meta-analysis showed that TEVAR in repairing the ruptured descending thoracic aorta was associated with lower perioperative mortality (OR=0.47; 95% CI: 0.34-0.66; p<0.01), 1 year mortality (OR=0.46; 95% CI: 0.29-0.75; p<0.01), renal insufficiency incidence (OR=0.56; 95% CI: 0.33-0.93; p=0.03), and pulmonary complications (OR=0.69; 95% CI: 0.52-0.92; p=0.01) when compared with OS. There was no significant difference between TEVAR and OS in terms of paraplegia, stroke, pulmonary embolism, cardiac complications, and early re-intervention rates. However, the late re-intervention rate was higher in the TEVAR group than that in the OS group. CONCLUSIONS When repairing the ruptured descending thoracic aorta, TEVAR may be performed rapidly and safely. TEVAR is associated with lower rates of perioperative morbidity and early postoperative complications than OS.
Collapse
Affiliation(s)
- Xinsheng Xie
- Department of Vascular Surgery, Xiamen Branch, Zhongshan hospital, Fudan University, Xiamen, China
| | - Xiaolong Shu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
| | - Wei Zhang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
| | - Wayne W Zhang
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA, USA
| | - Lixin Wang
- Department of Vascular Surgery, Xiamen Branch, Zhongshan hospital, Fudan University, Xiamen, China.,Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Xiamen Branch, Zhongshan hospital, Fudan University, Xiamen, China.,Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Vascular Surgery Institute of Fudan University, Shanghai, China
| |
Collapse
|
25
|
Ugajin A, Iwakoshi S, Ichihashi S, Inoue T, Nakai T, Kishida H, Chanoki Y, Tanaka T, Mori H, Kichikawa K. Prediction of Abdominal Aortic Aneurysm Growth After Endovascular Aortic Repair by Measuring Brachial-Ankle Pulse Wave Velocity. Ann Vasc Surg 2021; 81:163-170. [PMID: 34748949 DOI: 10.1016/j.avsg.2021.08.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Although endovascular aortic repair (EVAR) has become the dominant therapeutic approach for abdominal aortic aneurysm (AAA), continued sac growth after EVAR remains a major concern and is still unpredictable. Since AAA formation is thought to arise from atherosclerotic vascular damage of the aortic wall, we hypothesize that the severity of atherosclerosis in the AAA wall may influence sac growth. Therefore, we investigated whether brachial-ankle pulse wave velocity (baPWV), a marker of atherosclerosis severity obtained by noninvasive automatic devices, can predict sac growth after EVAR. METHODS The data from all patients who underwent elective EVAR for AAA at a single institution from January 2012 to March 2019 were reviewed. We extracted the baPWV before EVAR and divided patients into 2 groups according to the baPWV cut-off value identified by a classification and regression tree (CART). The primary outcome was significant sac growth, defined as an increment of 5 mm or more in aneurysm size after EVAR relative to the aneurysm size before EVAR. Cox regression analysis was performed to assess the potential predictors of sac growth. RESULTS During the follow-up period, 222 consecutive patients underwent elective EVAR for AAA. Of these, 175 patients with a median follow-up period of 36 months were included. The baPWV values were classified as <1854 cm/s (Group 0) in 100 patients and ≥1854 cm/s (Group 1) in 75 patients according to the cut-off value identified by CART. During the follow-up period, 10 (10.0%) patients in Group 0 and 18 (24.0%) patients in Group 1 demonstrated significant sac growth (P = 0.021). Risk factors for significant sac growth included baPWV (hazard ratio [HR], 3.059; 95% confidence interval [CI], 1.41-6.64; P = 0.005), age (HR, 1.078; 95% CI, 1.01-1.16; P = 0.036), and persistent type II endoleak (HR, 3.552; 95% CI, 1.69-7.48; P < 0.001). Multivariate analysis revealed that baPWV remained a significant risk factor for sac growth after adjustment for age (HR, 2.602; 95% CI, 1.15-5.82; P = 0.02) and persistent type II endoleak (HR, 2.957; 95% CI, 1.36-6.43; P = 0.006). CONCLUSIONS The baPWV before EVAR was associated with significant sac growth after EVAR; thus, measuring the baPWV may be useful for assessing the risk of future sac growth in patients after EVAR.
Collapse
Affiliation(s)
- Atsushi Ugajin
- Department of Radiology, IVR Center, Nara Medical University, Kashihara, Nara, Japan; Department of Radiology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Shinichi Iwakoshi
- Department of Radiology, IVR Center, Nara Medical University, Kashihara, Nara, Japan.
| | - Shigeo Ichihashi
- Department of Radiology, IVR Center, Nara Medical University, Kashihara, Nara, Japan
| | - Takashi Inoue
- Institute for Clinical Translational Science, Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Takahiro Nakai
- Department of Radiology, IVR Center, Nara Medical University, Kashihara, Nara, Japan
| | - Hayato Kishida
- Department of Radiology, IVR Center, Nara Medical University, Kashihara, Nara, Japan
| | - Yuto Chanoki
- Department of Radiology, IVR Center, Nara Medical University, Kashihara, Nara, Japan
| | - Toshihiro Tanaka
- Department of Radiology, IVR Center, Nara Medical University, Kashihara, Nara, Japan
| | - Harushi Mori
- Department of Radiology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Kimihiko Kichikawa
- Department of Radiology, IVR Center, Nara Medical University, Kashihara, Nara, Japan
| |
Collapse
|
26
|
Kordzadeh A, Sayed T, Ramirez MJ, Prionidis I, Howard A, Browne T. Abdominal Aortic Neck Wrap for Refractory Type 1a Endoleak: A Case Series and a Novel Intraoperative Assessment Technique. Ann Vasc Dis 2021; 14:19-22. [PMID: 33786095 PMCID: PMC7991699 DOI: 10.3400/avd.oa.20-00152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: Refractory type 1a endoleak after endovascular aneurysm repair (EVAR) can pose a significant challenge to surgeons and interventional radiologists. Continuous sac expansion results in aneurysm rupture and mortality. In such circumstances, an external infrarenal aortic wrap could serve as an essential and alternative solution. Methods: We assessed the application of an infrarenal aortic neck wrap for the treatment of refractory type 1a endoleak in n=6 consecutive patients along with the introduction of a novel assessment technique in order to assure their intraoperative success with no radiation exposure and contrast use. Results: The median sac expansion was 8.5 mm (interquartile range [IQR], 5-20 mm). The median neck diameter and length of the aortic neck were 23 mm (IQR, 18-25 mm) and 21 mm (IQR, 18-25 mm), respectively. The median length of follow-up post wrap is 24 months (IQR, 14-34 months). There was no associated mortality or morbidity and requirement for any further interventions. Conclusion: The study demonstrates that aortic wrapping for the treatment of refractory type 1a endoleak for any given neck diameter and length is safe, effective, and long lasting. The suggested novel intraoperative assessment technique contributes to the safety of the procedure by diminishing the need for intraoperative radiation exposure, contrast, and shorter operative time.
Collapse
Affiliation(s)
- Ali Kordzadeh
- Department of Vascular and Endovascular Surgery, Broomfield Hospital, Chelmsford, CM1 7ET, United Kingdom
| | - Tamer Sayed
- Department of Vascular and Endovascular Surgery, Broomfield Hospital, Chelmsford, CM1 7ET, United Kingdom
| | - Manfred J Ramirez
- Department of Vascular and Endovascular Surgery, Broomfield Hospital, Chelmsford, CM1 7ET, United Kingdom
| | - Ioannis Prionidis
- Department of Vascular and Endovascular Surgery, Broomfield Hospital, Chelmsford, CM1 7ET, United Kingdom
| | - Adam Howard
- East Suffolk & North Essex NHS Foundation Trust, Colchester General Hospital, Tumer Road, Colchester, Essex, C04 5JL, United Kingdom
| | - Tom Browne
- Department of Vascular and Endovascular Surgery, Broomfield Hospital, Chelmsford, CM1 7ET, United Kingdom
| |
Collapse
|
27
|
Andersson M, Talvitie M, Benson L, Roy J, Roos H, Hultgren R. A population-based study of post-endovascular aortic repair rupture during 15 years. J Vasc Surg 2021; 74:701-710.e3. [PMID: 33617983 DOI: 10.1016/j.jvs.2021.01.065] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 01/21/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The devastating event of a ruptured abdominal aortic aneurysm (rAAA) in patients who have survived a previous AAA repair, either elective or urgent, is a feared and quite uncommon event. It has been suggested to partly explain the loss of the early survival benefit for endovascular aortic repair (EVAR) vs open surgical repair (OSR). The main objective of this study was to report the national incidence rate, risk factors and outcome of post-EVAR ruptures. Secondarily, the national incidence rate of ruptures after OSR (post-OSR ruptures) was investigated. METHODS We conducted a nationwide, population-based, retrospective cohort study using the inpatient and outpatient entries for all patients >40 years of age, receiving their first (index) surgical procedure for AAA, from 2001 to 2015. Only patients surviving their index procedure were included. The primary outcome was rAAA, registered after discharge from the index procedure (EVAR or OSR), identified in the Swedish National Patient Registry and the Cause of Death Registry. RESULTS In total, 14,859 patients survived their primary (index) AAA procedure. There were 6470 EVAR procedures, 5893 for intact AAA (iAAA) and 577 for rAAA. Of the 6470 EVAR patients, 86 cases of post-EVAR rupture were identified, corresponding with a cumulative incidence of 1.3% over a mean follow-up time of 3.9 years. The incidence rate was 3.4 (95% confidence interval [CI], 2.7-4.2)/1000 person-years. The independent risk factors identified for post-EVAR rupture were rAAA at index surgery HR 2.4 (95% CI, 1.4-4.1, p 0.002) and age (hazard ratio, 1.1; 95% CI, 1.0-1.1; P < .001). Freedom from post-EVAR rupture was 99%, 98%, and 96% at 3, 5, and 10 years, respectively. Total and postoperative mortality after post-EVAR rupture were 42% and 17% (30 days), 45% and 22% (90 days), and 53% and 33% (1 year). The incidence rate of post-OSR rupture was 0.9/1000 person-years (95% CI, 0.7-1.2). CONCLUSIONS Post-EVAR rupture is a rare complication that can occur at any time after the index EVAR procedure. This finding may have implications for the discussion of limited follow-up programs and for the choice of procedure in patients with an AAA with a long life expectancy. An rAAA as the indication for the index surgery and age were identified as risk factors for post-EVAR rupture. The mortality associated with post-EVAR rupture is high, but lower than that of primary rAAA. The much lower risk of post-OSR rupture was confirmed, but must not be neglected as a possible late complication.
Collapse
Affiliation(s)
- Mattias Andersson
- Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sunderbyn Hospital, Sunderbyn, Sweden.
| | - Mareia Talvitie
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Lina Benson
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Håkan Roos
- Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Ryhov Hospital, Jönköping, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
28
|
Charisis N, Bouris V, Conway AM, Labropoulos N. A Systematic Review and Pooled Meta-Analysis on the Incidence and Temporal Occurrence of Type II Endoleak Following an Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2021; 75:406-419. [PMID: 33549794 DOI: 10.1016/j.avsg.2021.01.083] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/02/2021] [Accepted: 01/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim in this study was to systematically review the literature to identify the time of occurrence of a newly diagnosed Type II endoleak (T2E) following an endovascular aneurysm repair (EVAR) for an infrarenal abdominal aortic aneurysm (AAA) and its potential impact on aneurysmal sac diameter changes. METHODS A comprehensive systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane until January 2020. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess for heterogeneity. RESULTS Thirty-three observational studies were deemed eligible and provided data for 2643 T2E detected following EVAR. A total of 1432 (54.2%) T2E were diagnosed before 30 days follow-up, while 1035 (39.1%) T2E were diagnosed beyond 30 days following EVAR. A total of 222 (8.4%) T2E were diagnosed after 12 months of follow-up. A pooled meta-analysis of 6 studies, showed that early diagnosed T2E had a statistically significant higher odds of resolving as compared to those detected late (OR: 2.41; 95% CI: 1.14-5.09; P = 0.021; I2 = 68.9%). Sac expansion was documented in 313 (29%) T2E. The ruptured endoleaks were 14 (1.1%). CONCLUSIONS The occurrence of a T2E is a dynamic process detected throughout the lifetime of a patient with 8% detected beyond 12 months following EVAR. Long-term follow up is required with future prospective studies with consist reporting on changes in sac diameter, the thrombus characteristics. Long-term outcomes are needed to optimize management of patients with a newly diagnosed T2E.
Collapse
Affiliation(s)
- Nektarios Charisis
- Department of Vascular Surgery, Stony Brook University, Stony Brook, New York, USA
| | - Vasileios Bouris
- Department of Surgery, Lenox Hill Hospital, New York City, New York, USA
| | - Allan M Conway
- Department of Surgery, Lenox Hill Hospital, New York City, New York, USA
| | - Nicos Labropoulos
- Department of Vascular Surgery, Stony Brook University, Stony Brook, New York, USA.
| |
Collapse
|
29
|
De Santis F, Notari MP, Chiappa R. Early periaortic hematoma development after EVAR in the presence of severely calcified and modestly conical-shaped aortic neck: A potential trigger for sudden aneurysm progression toward rupture. Vascular 2020; 29:667-671. [PMID: 33308108 DOI: 10.1177/1708538120978030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this report is to present a singular case of early post-endovascular aneurysm repair abdominal aortic aneurysm rupture and discuss the possible etiopathogenic mechanism promoting the sudden aneurysm progression toward rupture.Methods/Results: An 84-year-old man was submitted to endovascular aneurysm repair via second-generation endograft (Cordis-Incraft Stent-graft) during which, the left occluded common iliac artery was recanalized via balloon-expandable covered-stent-graft (Atrium-Advanta-V12). The aneurysm presented a severely calcified and modestly conical-shaped aortic-neck. The post-operative course was complicated by a broncho pneumonic infiltrate and a CT scan performed two weeks postoperatively accidentally revealed a relatively small hematoma surrounding the aortic wall. No active bleeding, endoleak, or aneurysm increase in diameter was documented. Nevertheless, the patient remained closely monitored. Three days later, he suffered from abdominal aortic aneurysm rupture. A CT scan revealed an arterial wall tear at the neck level. Intra-operatively the reanalyzed common iliac artery was intact and a good endograft-sealing was confirmed. Following this event, small lumbar arteries suture saccotomy was performed. The patient eventually died of multiorgan failure one month later. CONCLUSIONS The apparently "self-limiting" post-endovascular aneurysm repair CT-scan finding of periaortic hematoma may have represented a potential trigger for abdominal aortic aneurysm rupture. The possibility of developing undetected aortic lesions during endovascular aneurysm repair, specifically in the presence of potentially "at risk" anatomical conditions, should always be considered.
Collapse
Affiliation(s)
| | | | - Roberto Chiappa
- Department of Vascular Surgery, Sandro Pertini Hospital, Rome, Italy
| |
Collapse
|
30
|
Banga P, Oderich GS, Farber M, Reis de Souza L, Tenorio ER, Timaran C, Schneider DB, Baumgardt Barbosa Lima G, Barreira Marcondes G, Timaran D. Impact of Number of Vessels Targeted on Outcomes of Fenestrated-Branched Endovascular Repair for Complex Abdominal Aortic Aneurysms. Ann Vasc Surg 2020; 72:98-105. [PMID: 33227467 DOI: 10.1016/j.avsg.2020.09.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 09/28/2020] [Accepted: 09/28/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The aim of this study was to investigate the impact of number of vessels targeted by fenestrations or branches on early outcomes of fenestrated-branched endovascular aortic repair (F-BEVAR) for complex abdominal aortic aneurysms (cAAAs). METHODS The clinical data of 260 patients (209 men; mean, 74 ± 7 years) treated for cAAAs in four academic centers using fenestrated-branched stent grafts with one to five fenestrations or branches were entered into prospectively maintained databases (2010-2015). Data were analyzed in patients treated with ≤2-vessel (group 1, n = 124), 3-vessel (group 2, n = 80), or ≥4 fenestrations or directional branches (group 3, n = 56). For group definition, only vessels incorporated by fenestrations or directional branches were accounted. End points were technical success, procedural variables, 30-day mortality, and major adverse events (MAEs). RESULTS A total of 830 vessels (mean, 3.19 ± 0.8 vessels/patient) were targeted by fenestrations (n = 672), scallops (n = 136), or branches (n = 22). Two-vessel designs were used more often in the early experience (64%), whereas ≥3-vessel design (groups 2 and 3) was preferred in the late experience (68%, P < 0.05). Patients with ≥4-vessel designs had longer operating and fluoroscopy time (+78 min, P < 0.0001 and + 27 min, P < 0.001), higher volume of contrast use (+31 mL, P = 0.03), and longer hospital stay (+3 days, P = 0.007) of those who had ≤2-vessel designs. Technical success, estimated blood loss, mortality, MAEs, and rate of spinal cord injury were similar in all three groups (P > 0.05). CONCLUSIONS F-BEVAR for complex abdominal aortic aneurysms was associated with high technical success and low 30-day mortality and morbidity. Increasing complexity was associated with longer operating and fluoroscopy time, more contrast use, and longer hospital stay but did not affect technical success and MAEs of the procedure.
Collapse
Affiliation(s)
- Peter Banga
- Division of Vascular and Endovascular Surgery, The Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX.
| | - Mark Farber
- The Division of Vascular Surgery, University of North Carolina Chapel Hill, NC
| | - Leonardo Reis de Souza
- Division of Vascular and Endovascular Surgery, The Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN
| | - Emanuel R Tenorio
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Carlos Timaran
- The Division of Vascular Surgery University of Texas South-Western Medical Center, Dallas, TX
| | - Darren B Schneider
- The Division of Vascular Surgery, Weill Cornell Medical Center, New York, NY
| | - Guilherme Baumgardt Barbosa Lima
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Giulianna Barreira Marcondes
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - David Timaran
- The Division of Vascular Surgery University of Texas South-Western Medical Center, Dallas, TX
| |
Collapse
|
31
|
Bredahl KK, Taudorf M, Ghulam QM, Rouet L, Sillesen HH, Eiberg JP. Three- and Two-Dimensional Ultrasound is as Accurate as Computed Tomography in Aortic Sac Assessment after Endovascular Aortic Repair. Ann Vasc Surg 2020; 72:321-329. [PMID: 33160060 DOI: 10.1016/j.avsg.2020.09.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND To compare aortic sac changes after endovascular aneurysm repair (EVAR) assessed by three-dimensional ultrasound (3D-US), two-dimensional ultrasound (2D-US), and traditional computed tomographic angiography (CTA). METHODS Using volume assessment with three-dimensional CTA (3D-CTA-volume) as the gold standard, this study investigated aortic sac changes at three and 12 months after EVAR with three different ultrasound methods (2D-US anterior-posterior (AP) diameter, 3D-US AP centerline diameter, and 3D-US partial volume), and traditional CT multiplanar outer-to-outer diameter (CT-MPR OTO diameter). From august 1st, 2011 to January 2014, consecutive EVAR patients (n = 113) were available for analysis in two time intervals; 1) between preoperative and three-month follow-up and 2) between three and 12 month follow-up. RESULTS The risk of missing true aortic sac growth (false negative finding) at three-month postoperative visit using 3D-US partial volume, 3D-US AP centerline diameter, 2D-US AP diameter, and CT-MPR OTO diameter was 19%, 21%, 22%, and 18%, respectively. Corresponding low sensitivities (0% to 21%) and kappa-values (<0.50) in detecting aortic sac changes were found. The risk of missing true growth between three and 12 months were lower (6%, 5%, 6%, and 6%, respectively), and matching sensitivities 33%, 33%, 17%, and 17%, respectively. CONCLUSIONS All tested methods for aortic sac changes were as good as traditional CT-MPR OTO diameter and corresponded poorly with 3D-CTA-volume at three months postoperative visit but substantially better after 12 months where the residual sac change was more profound.
Collapse
Affiliation(s)
- Kim K Bredahl
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Mikkel Taudorf
- Department of Radiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Qasam M Ghulam
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Henrik H Sillesen
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas P Eiberg
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Copenhagen Academy for Medical Education and Simulation (CAMES), Capital Region of Denmark, Copenhagen, Denmark
| |
Collapse
|
32
|
Natural history of isolated type II endoleaks in patients treated by fenestrated-branched endovascular repair for pararenal and thoracoabdominal aortic aneurysms. J Vasc Surg 2020; 72:44-54. [DOI: 10.1016/j.jvs.2019.09.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/13/2019] [Indexed: 11/21/2022]
|
33
|
Jean-Baptiste E, Feugier P, Cruzel C, Sarlon-Bartoli G, Reix T, Steinmetz E, Chaufour X, Chavent B, Salomon du Mont L, Ejargue M, Maurel B, Spear R, Midy D, Thaveau F, Desgranges P, Rosset E, Hassen-Khodja R, Bureau P, Ravoux M, Bozzetto C, Sevestre-Pietri MA, Terriat B, Favier C, Degeilh M, Le Hello C, Favre JP, Rinckenbach S, Loppinet A, Goueffic Y, Connault J, Alimi Y, Barthélémy P, Magne JL, Seinturier C, Choukroun ML, Rouyer O, Bitton L, Becquemin JP. Computed Tomography-Aortography Versus Color-Duplex Ultrasound for Surveillance of Endovascular Abdominal Aortic Aneurysm Repair. Circ Cardiovasc Imaging 2020; 13:e009886. [DOI: 10.1161/circimaging.119.009886] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Color-duplex ultrasonography (DUS) could be an alternative to computed tomography-aortography (CTA) in the lifelong surveillance of patients after endovascular aneurysm repair (EVAR), but there is currently no level 1 evidence. The aim of this study was to assess the diagnostic accuracy of DUS as an alternative to CTA for the follow-up of post-EVAR patients.
Methods
Between December 16, 2010, and June 12, 2015, we conducted a prospective, blinded, diagnostic-accuracy study, in 15 French university hospitals where EVAR was commonly performed. Participants were followed up using both DUS and CTA in a mutually blinded setup until the end of the study or until any major aneurysm-related morphological abnormality requiring reintervention or an amendment to the follow-up policy was revealed by CTA. Database was locked on October 2, 2017. Our main outcome measures were sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratios of DUS against reference standard CTA. CIs are binomial 95% CI.
Results
This study recruited prospectively 659 post-EVAR patients of whom 539 (82%) were eligible for further analysis. Following the baseline inclusion visit, 940 additional follow-up visits were performed in the 539 patients. Major aneurysm-related morphological abnormalities were revealed by CTA in 103 patients (17.2/100 person-years [95% CI, 13.9–20.5]). DUS accurately identified 40 patients where a major aneurysm-related morphological abnormality was present (sensitivity, 39% [95% CI, 29–48]) and 403 of 436 patients with negative CTA (specificity, 92% [95% CI, 90–95]). The negative predictive value and positive predictive value of DUS were 92% (95% CI, 90–95) and 39% (95% CI, 27–50), respectively. The positive likelihood ratio was 4.87 (95% CI, 2.9–9.6). DUS sensitivity reached 73% (95% CI, 51–96) in patients requiring an effective reintervention.
Conclusions
DUS had an overall low sensitivity in the follow-up of patients after EVAR, but its performance improved meaningfully when the subset of patients requiring effective reinterventions was considered.
Registration
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT01230203.
Collapse
Affiliation(s)
- Elixène Jean-Baptiste
- Service de Chirurgie Vasculaire, INSERM U1065, CHU de Nice, Université Côte D’Azur, Nice, France (E.J.-B., R.H.-K.)
| | - Patrick Feugier
- Service de Chirurgie Vasculaire, CHU Edouard Herriot, Université Claude Bernard Lyon1, Lyon, France (P.F.)
| | - Coralie Cruzel
- Délégation à la Recherche Clinique et à l’innovation, CHU de Nice, Université Côte D’Azur, Nice, France (C.C.)
| | - Gabrielle Sarlon-Bartoli
- C2VN, APHM, CHU Timone, Service de Chirurgie Vasculaire, Aix Marseille Université, Marseille, France (G.S.-B.)
| | - Thierry Reix
- Service de Chirurgie Vasculaire, CHU Amiens-Picardie, Université de Picardie Jules Verne, Amiens, France (T.R.)
| | - Eric Steinmetz
- Service de Chirurgie Vasculaire, CHU Dijon-Bourgogne, Université de Bourgogne, Dijon, France (E.S.)
| | - Xavier Chaufour
- Service de Chirurgie Vasculaire et angiologie, CHU de Toulouse, Université Paul Sabatier, Toulouse, France (X.C.)
| | - Bertrand Chavent
- Service de Chirurgie Cardio-Vasculaire, CHU de Saint-Etienne, Université Jean Monnet, Saint-Etienne, France (B.C.)
| | - Lucie Salomon du Mont
- Service de Chirurgie Vasculaire et Endovasculaire, CHU de Besançon, Université de Franche-Comté, Besançon, France (L.S.d.M.)
| | - Meghann Ejargue
- AP-HM, Department of Vascular Surgery, University Hospital Nord, Aix-Marseille Université, Marseille, France (M.E.)
| | - Blandine Maurel
- CHU Nantes, l’institut du thorax, service de chirurgie vasculaire, Inserm-UN UMR-957, Nantes, France (B.M.)
| | - Rafaelle Spear
- Service de Chirurgie Vasculaire, CHU de Grenoble, Université Grenoble-Alpes, Grenoble, France (R.S.)
| | - Dominique Midy
- Service de Chirurgie Vasculaire, CHU de Bordeaux, Bordeaux, France (D.M.)
| | - Fabien Thaveau
- Service de Chirurgie Vasculaire, CHU de Strasbourg, Strasbourg, France (F.T.)
| | - Pascal Desgranges
- Service de Chirurgie Vasculaire, CHU Henri Mondor, Créteil, France (P.D.)
| | - Eugenio Rosset
- Service de Chirurgie Vasculaire, CHU de Clermont-Ferrand, Université d’Auvergne, Clermont-Ferrand, France (E.R.)
| | - Réda Hassen-Khodja
- Service de Chirurgie Vasculaire, INSERM U1065, CHU de Nice, Université Côte D’Azur, Nice, France (E.J.-B., R.H.-K.)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Hosseini S, Rezaei Y, Alizadeh Ghavidel A. Challenges and experience of setting up an aortic service. Asian Cardiovasc Thorac Ann 2020; 29:669-676. [PMID: 32469677 DOI: 10.1177/0218492320930841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Aortic surgery is a complex procedure posing high risks in comparison to other adult cardiac surgeries. Novel surgical approaches including minimally invasive procedures, sutureless aortic valve replacement, and transcatheter aortic valve implantation have been found to be acceptable alternatives to conventional surgeries. In addition, novel endovascular repair techniques and hybrid procedures have been introduced for the management of patients with thoracoabdominal aortic pathologies. However, these modalities are not readily available in every center, and such novel procedures impose a learning curve for surgeons and high costs for affected patients. In this review, we discuss the challenges of setting up an aortic service, having regard to the Iranian experience.
Collapse
Affiliation(s)
- Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Alizadeh Ghavidel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
35
|
Meshii K, Sugimoto M, Niimi K, Kodama A, Banno H, Komori K. The association between perioperative embolization of hypogastric arteries and type II endoleaks after endovascular aortic aneurysm repair. J Vasc Surg 2020; 73:99-107. [PMID: 32442614 DOI: 10.1016/j.jvs.2020.04.505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/15/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Type II endoleaks (T2ELs) are the most common type of endoleak after endovascular aneurysm repair (EVAR). The iliolumbar artery arising from the hypogastric artery is often a major source of T2ELs, and transarterial embolization of the iliolumbar artery through the hypogastric artery is sometimes performed to interrupt sac expansion during follow-up. Considering the equivocal results of an association between hypogastric embolization and T2ELs in previous studies, this topic has re-emerged after the advent of iliac branch devices. This study reviewed our series to clarify whether hypogastric embolization is associated with T2ELs at 12 months after EVAR. METHODS Patients who underwent elective EVAR between June 2007 and May 2017 at our institution were retrospectively reviewed. Patients with postoperative computed tomography angiography (CTA) at 12 months were included. Patients in whom CTA revealed type I or type III endoleaks during follow-up, who required reinterventions before 12 months, and who had solitary iliac aneurysms were excluded. The primary outcome was the incidence of T2ELs at 12 months after EVAR. The associations of patients' characteristics, anatomic factors, hypogastric embolization, and type of endograft with the primary outcome were analyzed. RESULTS In total, 375 patients were enrolled. During the median follow-up of 59.5 months (interquartile range, 19-126 months), 40 patients died, and 50 reinterventions were performed. In 108 patients (28.8%), either hypogastric artery was embolized to extend distal landings to the external iliac artery. Bilateral and unilateral embolization was performed in nine and 99 patients, respectively. In total, 153 patients (40.8%) had T2ELs found by CTA at 12 months. In the univariate analysis, the status of hypogastric artery occlusion or embolization was not significantly different between patients with and without T2ELs. However, there were not enough patients to detect a 10% difference in T2ELs with >80% statistical power. In the multivariate analysis, significant associations with T2EL were observed for female sex (P = .049), patent inferior mesenteric artery (P = .006), and presence of five or more patent lumbar arteries (P < .001) but not for hypogastric embolization. In addition, compared with the Zenith (Cook Medical, Bloomington, Ind) endograft, the Excluder (W. L. Gore & Associates, Flagstaff, Ariz) endograft was significantly related to T2EL (P = .001). CONCLUSIONS No significant association between hypogastric embolization and T2EL was demonstrated in this retrospective study, which lacked adequate statistical power.
Collapse
Affiliation(s)
- Katsuaki Meshii
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayuki Sugimoto
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Kiyoaki Niimi
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Banno
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
36
|
Mid-term Outcomes and Predictors of Transarterial Embolization for Type II Endoleak After Endovascular Abdominal Aortic Aneurysm Repair. Cardiovasc Intervent Radiol 2020; 43:696-705. [PMID: 32140839 DOI: 10.1007/s00270-020-02436-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/15/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate the mid-term outcomes of transarterial embolization (TAE) for type II endoleak after endovascular abdominal aortic aneurysm repair (EVAR) and investigate the predictors of sac enlargement after embolization. MATERIALS AND METHODS We conducted a retrospective analysis of 55 patients [48 men and 7 women, median age 79.0 (interquartile ranges 74-82) years] who underwent TAE for type II endoleak from 2010 to 2018. The aneurysmal sac enlargement, endoleaks, aneurysm-related adverse event rate, and reintervention rate were evaluated. Patients' characteristics and clinical factors were evaluated for their association with sac enlargement. RESULTS Fifty-five patients underwent TAE with technical success and were subsequently followed for a median of 636 (interquartile ranges 446-1292) days. The freedom from sac enlargement rates at 1, 3, and 5 years was 73.2%, 32.0%, and 26.7%, respectively. After initial TAE, the recurrent type II, delayed type I, and occult type III endoleak were identified in 39 (71%), 5 (9%), and 3 (5%) patients, respectively. Although a patient had aorto-duodenal fistula, there was no aneurysm-related death. The freedom from reintervention rates was 84.6%, 35.7%, and 17.0%, respectively. In the multivariate analysis, sac diameter > 55 mm at initial TAE (hazard ratios, 3.23; 95% confidence intervals, 1.22-8.58; P < 0.05) was a significant predictor of sac enlargement. CONCLUSION TAE for type II endoleak was not effective in preventing sac enlargement, and reinterventions were required among the mid-term follow-up. The sac diameter > 55 mm at initial TAE was a significant predictor of sac enlargement.
Collapse
|
37
|
Stenson KM, de Bruin JL, Loftus IM, Holt PJ. Migration and sac expansion as modes of midterm therapeutic failure after endovascular aneurysm sealing. J Vasc Surg 2020; 71:457-469.e1. [DOI: 10.1016/j.jvs.2019.04.482] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 04/05/2019] [Indexed: 10/26/2022]
|
38
|
Katada Y. Recent Update of Endovascular Type 2 Endoleak Management. INTERVENTIONAL RADIOLOGY 2020; 5:114-119. [PMID: 36284754 PMCID: PMC9550397 DOI: 10.22575/interventionalradiology.2020-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/08/2020] [Indexed: 12/01/2022]
Abstract
EVAR has been used clinically for almost three decades, and it has been widely applied in clinical practice and has been applied to difficult cases as devices and techniques have evolved. Although the major advantage of EVAR is its lower perioperative mortality, compared with open surgery, late-onset complications such as endoleaks have become major issues, requiring lifelong follow-up after EVAR. The clinical guidelines have been updated, and many systematic reviews/meta-analyses and multi-center registries have been published; surgeons must keep up-to-date regarding these changes. In this review, the author reviews evidence on the recent update of the type 2 endoleak management.
Collapse
Affiliation(s)
- Yoshiaki Katada
- Department of Radiology, Tokyo Women's Medical University Medical Center East, Tokyo
| |
Collapse
|
39
|
D'Oria M, Mastrorilli D, Ziani B. Natural History, Diagnosis, and Management of Type II Endoleaks after Endovascular Aortic Repair: Review and Update. Ann Vasc Surg 2020; 62:420-431. [PMID: 31376537 DOI: 10.1016/j.avsg.2019.04.048] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/02/2019] [Accepted: 04/28/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Mayo Clinic Gonda Vascular Center, Rochester, MN; Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy.
| | - Davide Mastrorilli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Barbara Ziani
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| |
Collapse
|
40
|
Fujii T, Banno H, Kodama A, Sugimoto M, Akita N, Tsuruoka T, Sakakibara M, Komori K. Aneurysm Sac Thrombus Volume Predicts Aneurysm Expansion with Type II Endoleak After Endovascular Aneurysm Repair. Ann Vasc Surg 2019; 66:85-94.e1. [PMID: 31863957 DOI: 10.1016/j.avsg.2019.11.045] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/21/2019] [Accepted: 11/30/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Several studies have analyzed risk factors that may influence the incidence of type II endoleak with sac expansion after endovascular aneurysm repair (EVAR). However, the impact of intraluminal thrombus volume on the incidence of sac expansion with type II endoleak requires further analysis. This study examined the correlation between preoperative intraluminal thrombus and the incidence of type II endoleak and late sac expansion by measuring the thrombus volume. METHODS Between June 2007 and March 2014, 423 patients underwent EVAR at our institution. Two hundred and eighty patients with preoperative and postoperative computed tomography angiography (CTA) were included in this study. Data were collected prospectively and supplemented with a retrospective review of the medical records and radiologic images, and demographic and clinical characteristic profiles were collected. Logistic regression and Cox regression analyses were used to assess each variable's association with the incidences of persistent or new endoleak and sac expansion. RESULTS Of the 280 patients, 46.7% (131 patients) had persistent type II endoleak, and 19.6% (55 patients) had persistent type II endoleak with significant sac expansion (≥5 mm). The mean follow-up duration was 60 months (interquartile range, 24-72 months). Cox regression analysis showed that older age (P = 0.001), intraluminal thrombus volume ratio (thrombus volume [T vol]/aortic aneurysm volume [A vol]) (P = 0.042) and IMA diameter (P = 0.004) were significant predictors of the incidence of sac expansion with persistent or new type II endoleak. The receiver operating characteristic curve analysis revealed a cutoff of 51% T vol/A vol (area under the curve [AUC]: 0.59) and 2.9 mm (area under the curve [AUC]: 0.60). The rate of freedom from sac expansion (≥5 mm) during followup was significantly higher in patients with ≥51% T vol/A vol than in those with a lower T vol/A vol (P = 0.010). CONCLUSIONS Preoperative sac thrombus volume, IMA diameter, and older age predict the incidence of aneurysm expansion with type II endoleak after EVAR.
Collapse
Affiliation(s)
- Takayuki Fujii
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Hiroshi Banno
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayuki Sugimoto
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naohiro Akita
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Tsuruoka
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masashi Sakakibara
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
41
|
Abdul Jabbar A, Chanda A, White CJ, Jenkins JS. Percutaneous endovascular abdominal aneurysm repair: State‐of‐the art. Catheter Cardiovasc Interv 2019; 95:767-782. [DOI: 10.1002/ccd.28576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/27/2019] [Accepted: 10/25/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Ali Abdul Jabbar
- Interventional CardiologyOchsner Clinic Foundation New Orleans Louisiana
| | - Arijit Chanda
- Interventional CardiologyOchsner Clinic Foundation New Orleans Louisiana
| | | | | |
Collapse
|
42
|
Jetty P, Husereau D, Kansal V, Zhang T, Nagpal S. Variability in aneurysm sac regression after endovascular aneurysm repair based on a comprehensive registry of patients in Eastern Ontario. J Vasc Surg 2019; 70:1469-1478. [DOI: 10.1016/j.jvs.2019.01.091] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 01/22/2019] [Indexed: 12/01/2022]
|
43
|
Plá Sánchez F, Martínez López I, Hernández Mateo MM, Marqués de Marino P, Ucles Cabeza O, Baturone Blanco A, Serrano Hernando FJ. Prognostic Value of Initial Aneurysmal Sac Regression after EVAR. Ann Vasc Surg 2019; 64:109-115. [PMID: 31629125 DOI: 10.1016/j.avsg.2019.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 08/11/2019] [Accepted: 09/05/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The objective of the study was to evaluate the impact of initial aneurysmal sac reduction after endovascular aneurysm repair on the evolution of aneurysmal sac over follow-up. METHODS A retrospective cohort study was made of patients subjected to elective treatment between January 2005 and December 2014, with a minimum follow-up of 18 months. An analysis was made of the evolution of the aneurysmal sac according to its condition one year after surgery, defining of two groups: A (sac reduction) and B (stable sac). Follow-up by computed tomography (CT) angiography was made after one month and then every 6 months or annually, depending on the presence of endoleak. RESULTS A total of 128 patients were included. Fifty-one patients (39.8%) showed a significant decrease in diameter during the first year (group A), whereas 77 patients (60.2%) showed no initial decrease (group B). Preoperative CT angiography showed the patients in group A to have larger aneurysms (63.5 mm vs. 59.25; P = 0.048), a greater presence of posterior thrombus (68.6% vs. 30.7%; P < 0.001), and fewer patent lumbar vessels (56.9% vs. 83.1%; P = 0.001). The prevalence of endoleak at some point during follow-up was lower in group A (31.4% vs. 74% in group B; P < 0.001), and 100% of all aneurysmal growths were associated to the presence of endoleak. After 5 years, significant differences were observed in the growth-free rate (96.9% in group A vs. 85.2% in group B; hazard ratio [HR] 4.8 [1.1-21.4; P = 0.036]) and in the reintervention-free rate (95,7% vs. 84.6%; HR 6.6 [0.8-52.4; P = 0.07]). No reoperation in group A was due to type II endoleak. CONCLUSIONS The aneurysmal sac can be expected to take a favorable course in those cases characterized by initial aneurysmal sac reduction. These findings may imply a change in the follow-up protocol, even in cases with type II endoleak.
Collapse
Affiliation(s)
- Ferrán Plá Sánchez
- Angiology and Vascular Surgery Department, San Carlos Clinical Hospital, Madrid, Spain.
| | - Isaac Martínez López
- Angiology and Vascular Surgery Department, San Carlos Clinical Hospital, Madrid, Spain
| | | | | | - Oscar Ucles Cabeza
- Angiology and Vascular Surgery Department, San Carlos Clinical Hospital, Madrid, Spain
| | | | | |
Collapse
|
44
|
Optimizing Surveillance and Re-intervention Strategy Following Elective Endovascular Repair of Abdominal Aortic Aneurysms. Ann Surg 2019; 274:e589-e598. [PMID: 31592810 DOI: 10.1097/sla.0000000000003625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND EVAR for abdominal aortic aneurysm has an initial survival advantage over OR, but more frequent complications increase costs and long-term aneurysm-related mortality. Randomized controlled trials of EVAR versus OR have shown EVAR is not cost-effective over a patient's lifetime. However, in the EVAR-1 trial, postoperative surveillance may have been sub-optimal, as the importance of sac growth as a predictor of graft failure was overlooked. METHODS Real-world data informed a discrete event simulation model of postoperative outcomes following EVAR. Outcomes observed EVAR-1 were compared with those from 5 alternative postoperative surveillance and re-intervention strategies. Key events, quality-adjusted life years and costs were predicted. The impact of using complication and rupture rates from more recent devices, imaging and re-intervention methods was also explored. RESULTS Compared with observed EVAR-1 outcomes, modeling full adherence to the EVAR-1 scan protocol reduced abdominal aortic aneurysm (AAA) deaths by 3% and increased elective re-interventions by 44%. European Society re-intervention guidelines provided the most clinically effective strategy, with an 8% reduction in AAA deaths, but a 52% increase in elective re-interventions. The cheapest and most cost-effective strategy used lifetime annual ultrasound in primary care with confirmatory computed tomography if necessary, and reduced AAA-related deaths by 5%. Using contemporary rates for complications and rupture did not alter these conclusions. CONCLUSIONS All alternative strategies improved clinical benefits compared with the EVAR-1 trial. Further work is needed regarding the cost and accuracy of primary care ultrasound, and the potential impact of these strategies in the comparison with OR.
Collapse
|
45
|
The structural atrophy of the aneurysm wall in secondary expanding aortic aneurysms with endoleak type II. J Vasc Surg 2019; 70:1318-1326.e5. [DOI: 10.1016/j.jvs.2018.10.091] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 10/04/2018] [Indexed: 01/09/2023]
|
46
|
Rich N, Tucker LY, Okuhn S, Hua H, Hill B, Goodney P, Chang R. Long-term freedom from aneurysm-related mortality remains favorable after endovascular abdominal aortic aneurysm repair in a 15-year multicenter registry. J Vasc Surg 2019; 71:790-798. [PMID: 31495678 DOI: 10.1016/j.jvs.2019.05.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 05/08/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Endovascular aneurysm repair (EVAR) has become the preferred approach to abdominal aortic aneurysm (AAA) because of lower early morbidity and mortality than open repair. However, the ability of EVAR to prevent long-term aneurysm-related mortality (ARM) has been questioned in light of recent trial data. We have updated our long-term EVAR experience in a large multicenter registry to further examine this issue. METHODS Between 2000 and 2010, 1736 patients with AAA underwent EVAR in a large integrated regional healthcare system. We extended follow-up in this previously reported cohort through 2015 and identified predictors associated with ARM and need for major reintervention. The primary outcome was ARM. Secondary outcomes were all-cause mortality, delayed aneurysm rupture, major adverse event, major reintervention, sac growth of more than 5 mm, and type I or III endoleak. End points were analyzed for the whole cohort and compared for patients who underwent EVAR during the earlier (2000-2005) and latter (2006-2010) halves of the enrollment period to assess for changes in outcomes over time of repair. RESULTS The overall follow-up rate was 96.3%, and median follow-up was 5.5 years (interquartile range, 2.8-7.7 years). During the study period, 958 patients died, of whom 63 experienced ARM (6.6%). Overall crude rate of freedom from ARM was 96.4%. Delayed aneurysm rupture was seen in 1.3% (n = 23), with a median time to event of 4.1 years (interquartile range, 1.7-7.2 years). Major adverse events occurred in 12.4% of patients, and major reintervention was performed in 10.3%. Overall freedom from major adverse event or major reintervention was seen in 84.0%. Significant predictors of ARM included female sex, age 80 to 89 years, urgent EVAR, and any major reintervention. The unadjusted cumulative probability of all-cause survival was significantly higher in the late group than the early group at 5 years (66.8% vs 59.8%; P = .01, log-rank test); however, freedom from ARM at 5 years was not significantly different (96.5% and 97.1%, respectively; P = .67, log-rank test). CONCLUSIONS Our results demonstrate favorable long-term freedom from major adverse event or major reintervention after EVAR and extremely low rates of ARM and delayed rupture. Our findings support EVAR as a safe, long-term solution for managing patients with AAA and provide insight into clinical parameters that can be used to stratify patients' post-EVAR surveillance and need for reintervention.
Collapse
Affiliation(s)
- Nicole Rich
- Department of Surgery, University of California San Francisco, San Francisco, Calif
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Oakland, Calif
| | - Steven Okuhn
- Vascular and Endovascular Surgery, VA San Francisco Health Care System, San Francisco, Calif
| | - Hong Hua
- Department of Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | - Bradley Hill
- Department of Vascular Surgery, Permanente Medical Group, Santa Clara, Calif
| | - Philip Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Robert Chang
- Department of Vascular Surgery, Permanente Medical Group, South San Francisco, Calif.
| |
Collapse
|
47
|
Whaley ZL, Cassimjee I, Novak Z, Rowland D, Lapolla P, Chandrashekar A, Pearce BJ, Beck AW, Handa A, Lee R. The Spatial Morphology of Intraluminal Thrombus Influences Type II Endoleak after Endovascular Repair of Abdominal Aortic Aneurysms. Ann Vasc Surg 2019; 66:77-84. [PMID: 31394212 PMCID: PMC7327520 DOI: 10.1016/j.avsg.2019.05.050] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/20/2019] [Accepted: 05/24/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Type 2 endoleaks (T2Es) after endovascular repair (EVAR) of abdominal aortic aneurysm (AAA) can lead to sac expansion or failure of sac regression, and often present as a management dilemma. The intraluminal thrombus (ILT) may influence the likelihood of endoleaks after EVAR and can be characterized using routine preoperative imaging. We examined the relationship between preoperative spatial morphology of ILT and the incidence of postoperative T2E. METHODS All patients who underwent EVAR at the John Radcliffe Hospital (Oxford, UK) were prospectively entered in a clinical database. Computed tomography angiograms (CTAs) were performed as part of routine clinical care. The ILT morphology of each patient was determined using the preoperative CTA. Arterial phase cross-sectional images of the AAA were analyzed according to the presence and morphology of the thrombus in each quadrant. The overall ILT morphology was defined by measurements obtained over a 4-cm segment of the AAA. The diagnosis of T2Es during EVAR surveillance was confirmed by CTAs. The relation between the ILT morphology and T2E was assessed using logistic regression. RESULTS Between September 2009 and July 2016, 271 patients underwent EVAR for infrarenal AAAs (male: 241, age = 79 ± 7). The ILT was present in 265 (98%) of AAAs. Mean follow-up was 1.9 ± 1.6 years. The T2E was observed in 77 cases. Sixty-one percent of T2Es were observed within the first week after surgery. The T2E was observed in 50% (3/6) of cases without the ILT (no-ILT). Compared with no-ILT, the presence of circumferential or posterolateral ILTs was protective from T2Es (odds ratio = 0.33 and 0.37; P = 0.002 and P = 0.047, respectively). CONCLUSIONS The spatial ILT morphology on routine preoperative CTA imaging can be a biomarker for post-EVAR T2Es. ILTs that cover the posterolateral aspects of the lumen, or circumferential ILTs, are protective of T2Es. This information can be useful in the preoperative planning of EVARs.
Collapse
Affiliation(s)
- Zachary L Whaley
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Ismail Cassimjee
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - David Rowland
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | | | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Ashok Handa
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Regent Lee
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
| | | | | |
Collapse
|
48
|
Quan C, Oh YK, Park SC, Won YS, Yun SS, Suh YJ, Kim JY. Efficacy of volumetric analysis of aorta as surveillance tool after EVAR. Asian J Surg 2019; 42:746-754. [DOI: 10.1016/j.asjsur.2018.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 10/05/2018] [Accepted: 12/17/2018] [Indexed: 10/27/2022] Open
|
49
|
Mayette M, St-Arnaud C. Aortic stent graft leak and aneurysm rupture after alteplase for stroke. CMAJ 2019; 191:E709-E711. [PMID: 31235491 PMCID: PMC6592809 DOI: 10.1503/cmaj.181698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Michael Mayette
- Department of Medicine, Internal Medicine and Critical Care Division (Mayette, St-Arnaud), Université de Sherbrooke, Sherbrooke, Que.
| | - Charles St-Arnaud
- Department of Medicine, Internal Medicine and Critical Care Division (Mayette, St-Arnaud), Université de Sherbrooke, Sherbrooke, Que
| |
Collapse
|
50
|
Unsgård RG, Altreuther M, Lange C, Hammer T, Mattsson E. Five-year results of endovascular aortic repair used according to instructions for use give a good general outcome for abdominal aortic aneurysm. SAGE Open Med 2019; 7:2050312119853434. [PMID: 31205704 PMCID: PMC6535726 DOI: 10.1177/2050312119853434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/07/2019] [Indexed: 11/16/2022] Open
Abstract
Objectives: The primary aim of this study was to investigate the rate of sac enlargement and secondary procedures after 5 years when instructions for use are strictly applied with endovascular aortic repair. The secondary aim was to investigate if strict indications with endovascular aortic repair, rendering more open operations, would change the general outcome of patients with abdominal aortic aneurysm. Materials and methods: Patients having their abdominal aortic aneurysm procedure in a single institution between 01 January 2002 and 31 December 2006 were included. Indications for endovascular aortic repair were as follows: aortic neck: length 15 mm or more, diameter 32 mm or less and straight configuration; iliac arteries: length > 10 mm, 7.5–20 mm in diameter. Sac enlargement was defined as an increase in diameter of 5 mm or more. Results: A total of 123 patients were intended to be treated electively with endovascular aortic repair from 2002 to 2007 using Cook Zenith stent grafts. In the same period, 147 patients were treated with elective open repair. At 5 years, 7.3% (N = 9) of the elective intended-to-treat patients with endovascular aortic repair had a sac enlargement. Thirty-five percent of the patients were registered with endoleaks, 13% of the patients had secondary procedures, 12.2% of the patients had early and 6.5% late complications during the follow-up period. Aneurysm rupture was seen in 1.6% of the patients. During the 5-year follow-up period, 34 (27.6%) of the endovascular aortic repair patients died. Five-year mortality for open repair was 23.8%, and 12.2% of the open repair patients had secondary procedures. Conclusion: Endovascular aortic repair for abdominal aortic aneurysm in accordance with instructions for use gives a low long-term risk for increased diameter and low rate of secondary procedures. There was similar mortality after elective endovascular aortic repair and open repair for abdominal aortic aneurysm. Applying endovascular aortic repair according to instructions for use does not seem to change the general outcome of patients with abdominal aortic aneurysm but improves the outcome with the method.
Collapse
Affiliation(s)
- Runa G Unsgård
- Department of Radiology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Martin Altreuther
- Department of Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Conrad Lange
- Department of Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Tommy Hammer
- Department of Radiology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Erney Mattsson
- Department of Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| |
Collapse
|