Frequency and Outcome of Re-interventions after Endovascular Repair for Abdominal Aortic Aneurysm: A Prospective Cohort Study

Secondary interventions following endovascular abdominal aortic aneurysm repair using current endografts. A EUROSTAR report

OBJECTIVE

The purpose of this study was to evaluate the need for secondary interventions after endovascular abdominal aortic aneurysm repair with current stent-grafts.

METHODS

Studied were data from 2846 patients treated from December 1999 until December 2004. The data were recorded from the EUROSTAR registry. The only patients studied were those with a follow-up of at least 12 months or until they had a secondary intervention within the first 12 months. The cumulative incidences of secondary transabdominal, extra-anatomic, and transfemoral interventions during follow-up (after the first postoperative month) were investigated.

RESULTS

A secondary intervention was performed in 247 patients (8.7%) at a mean of 12 months after the initial procedure within a follow-up period of a mean of 23 +/- 12 months. Of these, 57 (23%) transabdominal, 43 (16%) involved an extra-anatomic bypass, and 147 (60%) were by transfemoral approach. The cumulative incidence of secondary interventions was 6.0%, 8.7%, 12%, and 14% at 1, 2, 3, and 4 years, respectively. This corresponded with an annual rate of secondary interventions of 4.6%, which was remarkably lower than in a previously published EUROSTAR study of patients treated before 1999. Type I endoleaks (33% of procedures), migration (16%), and rupture (8.8%) were the most frequent reasons for secondary transabdominal interventions. Graft limb thrombosis was the indication for extra-anatomic bypass (60%). Type I endoleak (17%), type II endoleak (23%), device limb stenosis (14%), thrombosis (23%), and device migration (14%) were the most frequent reasons for secondary transfemoral interventions. Operative mortality was higher after secondary transabdominal interventions (12.3%, P = .007) compared with transfemoral interventions (2.7%). Overall survival was lower in patients with secondary transabdominal (P = .016) and extra-anatomic interventions (P < .0001) compared with patients without a secondary intervention.

CONCLUSION

Although the incidence of secondary interventions after endovascular aneurysm repair has substantially decreased in recent years, continuing need for surveillance for device-related complications remains necessary.

Endovascular treatment of iliac artery aneurysms with a tubular stent-graft: mid-term results

OBJECTIVE

To report the mid term results of a prospective cohort of iliac artery aneurysms (IAAs) treated with endovascular tubular stent-grafts.

METHODS

All IAAs referred to the University Medical Center Groningen between June 1998 and June 2005 were evaluated for endovascular repair. Criteria for repair were a diameter of > or = 30 mm for anastomotic aneurysms and > or = 35 mm for true aneurysms. Preferentially, tubular grafts were used. Follow-up included both radiographs of the abdomen and duplex examination.

RESULTS

In 35 patients, 40 IAAs were treated endovascularly with a tubular stent-graft. Elective repair was performed in 30 patients (86%) and emergent repair in five patients (14%). Aneurysms were false in 26 cases (65%) and true in 14 cases (35%). Local anesthesia was used in 74% of the cases. The stent-grafts that were used included the Excluder contralateral limb (n = 28, 70%), Passager (n = 9, 22.5%), Hemobahn (n = 2, 5%), and Wallgraft (n = 1, 2.5%). The mean operation time was 83 +/- 28 minutes (range, 50 to 150 minutes). Mean hospital stay was 3.3 +/- 2.3 days (range, 1 to 12 days). There was no 30-day mortality. Patients were followed up for a mean of 31.2 +/- 20.7 months (range, 3 to 83 months). Complications occurred in two patients during follow-up, including migration with a proximal type I endoleak in one, and occlusion of the stent-graft in the other. The internal iliac artery was intentionally sacrificed in 28 patients (70%), and this led to gluteal claudication in three patients.

CONCLUSION

Endovascular repair of iliac artery aneurysms with flexible stent-grafts is a minimally invasive technique and is associated with low mortality and morbidity. Follow-up results up to 5 years suggest that the technique is durable. It should be regarded as a first choice treatment option for suitable aneurysms.

Laparoscopy-assisted abdominal aortic aneurysm repair: Early and middle-term results of a consecutive series of 122 cases

BACKGROUND

Endoaneurysmorrhaphy with intraluminal graft placement, described by Creech, is the gold standard for abdominal aortic aneurysm (AAA) repair. Endovascular aneurysm repair has gained popularity for its minimal invasiveness and satisfying short-term results, but there are still many concerns about the long-term success of the procedure. Since 1998, laparoscopic surgery has been proposed for AAA treatment. The potential benefits of a minimally invasive procedure reproducing the endoaneurysmorrhaphy results over time have been advocated. In our experience, hand-assisted laparoscopic surgery (HALS) has been routinely used for the open-surgery transperitoneal/retroperitoneal approach and for endovascular aneurysm repair. After 4 years, we are able to define the early and middle-term results of such laparoscopic-assisted treatment.

METHODS

From October 2000 to March 2004, 604 consecutive nonurgent AAAs were treated at our institution. Of these, 122 (20.2%) were treated by HALS. Exclusion criteria for HALS were hostile abdomen (previous major abdominal or aortic surgery), bilateral diffuse common iliac and/or hypogastric aneurysms, massive aortoiliac calcifications, and severe cardiac (ejection fraction <35%) and respiratory (P(O2) <60 mm Hg or carbon dioxide >50 mm Hg) insufficiency. Juxtarenal and proximal iliac aneurysms were not a contraindication, nor was obesity. In all patients, we performed a minilaparotomy (7-8 cm) both for laparoscopic hand-assisted dissection and for endoaneurysmorrhaphy. All perioperative data were prospectively recorded. Follow-up consisted of ultrasonography and clinical evaluation after 6 and 12 months and then every year after surgery.

RESULTS

The mean laparoscopic and total operative times were respectively 64 +/- 32 minutes and 257 +/- 70 minutes, the mean aortic cross-clamping time was 76 +/- 26 minutes, and the mean autotransfused blood volume was 1136 +/- 711 mL. The overall mortality and morbidity were respectively 0% and 12.2%. Morbidity was surgery related in only two cases (bleeding from an ipogastric artery lesion and a leg graft thrombosis). The mean intensive care unit stay was 14.3 +/- 13 hours. Oral food intake was resumed after 27.4 +/- 15 hours, and patients were discharged after a mean of 4.4 +/- 1.7 days. Operative times were not affected by obesity, suprarenal aortic cross-clamping, or aneurysm size. Both concomitant iliac aneurysms and bifurcated graft implantation (related to longer vascular reconstruction) involved significantly longer operative times. The learning curve of the procedure (comparing the first 30 patients with the last 92 patients) led to significantly shorter endoscopic, cross-clamping, and total operative times (P = .000). The mean follow-up was 28.6 +/- 16 months. Three incisional hernias and one case of bowel occlusion were detected. All these cases (3.4%) required laparoscopic treatment.

CONCLUSIONS

The HALS technique is a safe and minimally invasive treatment for AAA; it is useful for limiting the need for conventional open surgery and reducing the length of hospital stay. Despite the lack of randomized studies, HALS seems to be associated with a better postoperative course than standard open surgery. HALS can also be considered as an equivalent of a well-established procedure and as a bridge between open and total laparoscopic surgery.

Stent-Grafts for Unruptured Abdominal Aortic Aneurysms: Current Status

Aortic stent-grafts were introduced at the beginning of the 1990s as a less invasive method of dealing with aortic aneurysms in patients with poor cardiovascular reserve. The numbers of procedures performed worldwide has increased exponentially despite the current lack of any substantial evidence for long-term efficacy in comparison with the gold standard of open surgical grafting. This review summarizes the evolution of the abdominal aortic stent-graft, the techniques used for assessment and deployment, and the effect of the procedure on both the patient and the device. The recent publication of two national multicenter trials has confirmed that the endovascular technique confers a 2.5-fold reduction in 30-day mortality in comparison with open surgery. However, over 4 years of follow-up, there is a 3-fold increase in the risk of reintervention and the overall costs are 30% greater with endovascular repair. Although the improvement in aneurysm-related mortality persists in the mid-term, because of the initial reduction in perioperative mortality, the all-cause mortality rate at 4 years is actually no better than for open surgery. Longer-term data from the randomized trials are awaited as well as results from the latest trials utilizing state-of-the-art devices. Whilst the overall management of abdominal aortic aneurysms has undoubtedly benefited from the introduction of stent-grafts, open repair currently remains the gold standard treatment.

Dynamic CE-MRA for Endoleak Classification after Endovascular Aneurysm Repair

AIM

To evaluate the value of dynamic contrast enhanced magnetic resonance angiography (CE-MRA) for classification of endoleaks after endovascular aneurysm repair (EVAR).

MATERIALS AND METHODS

Twenty-eight patients, between 2 days and 54 months after EVAR, were evaluated with CTA, MRI and dynamic CE-MRA. The additional diagnostic value of the dynamic 3D CE-MRA was evaluated by determining the ability of the dynamic series in pinpointing the site of inflow of an endoleak.

RESULTS

An endoleak was detected in 23 patients. Seventeen of the 23 dynamic series were technically successful (no disturbing artifacts limiting the diagnostic value). Using MRI our findings were: 2 type I, 6 type II, 1 type III, no type IV endoleaks and in 14 cases classification could not be made. The classification results for MRI plus the dynamic CE-MRA were: 2 type I, 12 type II, 1 type III, no type IV endoleaks and in eight cases classification could not be made. In six cases the dynamic MRA allowed classification of the endoleak, which was not possible with the non-dynamic images alone (p=0.091, Fisher exact).

CONCLUSION

This pilot study shows that dynamic CE-MRA can have additional value in the classification of endoleaks. Dynamic CE-MRA might obviate the need for diagnostic digital subtraction angiography and aid planning for intervention.

Long-term outcome after Talent endograft implantation for aneurysms of the abdominal aorta: A multicenter retrospective study

BACKGROUND

The development of newer-generation endografts for the endovascular treatment of abdominal aortic aneurysms has resulted in considerable improvements in clinical performance. However, long-term outcome data are still scarce. To assess long-term clinical and radiographic outcomes after use of the Talent stent graft, a retrospective analysis was performed that was based on 165 patients treated with this endograft in Germany between October 1996 and December 1998.

METHODS

Data were collected according to the recommendation of the ad hoc committee for standardized reporting practices in vascular surgery and were evaluated statistically by using univariate and multivariate analyses.

RESULTS

A total of 165 patients were treated with a Talent endograft in 9 German centers before December 31, 1998. Most were asymptomatic (94.5%), male (97.6%), and treated with a bifurcated graft (86.7%). Two patients (1.2%) died within 30 days, and 28 (17%) died during the follow-up period. The cause of death was aneurysm rupture in one case. Survival was 95.4% +/- 1.7% at 1 year, 89% +/- 2.6% at 2 years, 78.1% +/- 3.6% at 5 years, and 76.2% +/- 4.1% at 7 years. Patients classified as American Society of Anesthesiologists grade IV had a significantly lower survival rate (24.9%) than those classified as American Society of Anesthesiologists grade II and III (91.9% and 77.3%). During a mean follow-up period of 53.2 +/- 20.1 months (range, 1-84 months), 47 secondary procedures were performed in 31 patients (18.8%). Kaplan-Meier estimates showed a freedom from secondary intervention of 94.7% +/- 1.8%, 81.7% +/- 3.3%, and 77.4% +/- 3.6% at 1, 3, and 7 years, respectively. The reason for secondary treatment was endograft thrombosis in 10 patients (6.1%), persisting primary endoleak in 9 (5.5%), late secondary endoleak in 6 (3.6%), graft migration in 3 (1.8%), aneurysm rupture in 2 (1.2%), and graft infection in 1 (0.6%). Device migration (> or =10 mm) occurred in seven patients (4.2%). Other graft changes, such as graft kinking (n = 4; 2.4%), fracture of metallic stents (n = 2; 1.2%), erosion of the longitudinal bar (n = 2; 1.2%), or modular component separation (n = 1; 0.6%), were rare. Follow-up computed tomographic imaging revealed a decrease of the maximum aneurysm sac diameter (>5 mm) in 106 (64.2%) patients and an increase in 14 (8.5%) patients. The mean aneurysm diameter significantly decreased (P < .001). Of the factors recorded at baseline, only endoleaks showed a significant correlation with the risk of aneurysm increase during follow-up (P < .001). Adverse anatomy (neck diameter >28 mm, neck length <15 mm, and '5 patent aortic branches) did not adversely influence the aneurysm shrinkage rate, the risk for a secondary procedure, or the clinical success rate. A significantly higher rate of clinical success (P < .05) was observed in patients older than 65 years of age.

CONCLUSIONS

Implantation of the Talent endograft device is a safe and effective alternative to open surgery for exclusion of abdominal aortic aneurysm. In comparison with first-generation grafts, the device showed superior durability for as long as 5 to 7 years after implantation. Even if prototypes of the Talent device were implanted in this study, the graft was also successfully used in most patients, even in those with adverse anatomy. Because improvements of the endograft have been made to address connecting bar breaks, a lower incidence of graft limb occlusion can be expected in the future.