Embolic complications after endovascular repair of abdominal aortic aneurysms

Acute limb ischemia in the elderly: Determining the mortality factors

Background

The study aims to identify factors associated with mortality in elderly patients undergoing surgery for acute limb ischemia.

Methods

Between October 2010 and January 2024, a total of 205 patients (106 males, 99 females; mean age: 77.7±8.0 years; range, 65 to 98 years) who underwent embolectomy for acute limb ischemia were retrospectively analyzed. Postoperative mortality and one-year mortality were designated as primary outcome measures. Multiple regression analyses were performed for variables related to postoperative mortality, and cut-off values for numeric variables were determined. The Kaplan-Meier survival analyses were performed using one-year mortality data.

Results

Postoperative mortality rate was 35.1% and oneyear mortality rate was 56.6%. A total of 52.8% of the patients who died postoperatively were functionally dependent and 72.2% had no history of atrial fibrillation. Multivariate analysis revealed that a neutrophil-to-lymphocyte ratio above 5.91 increased mortality by 9.1 times, functional dependency by 7.3 times, and absence of a history of atrial fibrillation by 3.3 times. Functional dependency, absence of atrial fibrillation, and neutrophil-to-lymphocyte ratio greater than 5.85 negatively affected one-year mortality.

Conclusion

Our study results indicate that absence of atrial fibrillation, functional dependency, and neutrophil-to-lymphocyte ratio can be used to predict postoperative mortality.

Descending thoracic aortic mural ulceration is associated with postoperative spinal cord ischemia after branched endovascular aortic aneurysm repair

OBJECTIVE

Paraplegia is one of the most feared complications after thoracoabdominal aortic aneurysm repair. The purpose of this study is to determine whether aortic thrombus characteristics are associated with spinal cord ischemia (SCI) after branched endovascular aneurysm repair (BEVAR).

METHODS

From April 2011 to April 2020, 62 patients underwent elective BEVAR for thoracoabdominal aortic aneurysm and pararenal aortic aneurysms using a low-profile device and had a complete preoperative computed tomography angiography of the aorta from the sinotubular junction to the aortic bifurcation. Aortic thrombus was evaluated for thrombus thickness ≥5 mm, thrombus >2/3 of aortic circumference, and the presence of an ulcer-like thrombus. One point was assigned at each 5 mm axial image if all 3 criteria were met, resulting in a total "shaggy score" for the entire aorta. Data on demographics, procedural details, and outcomes were collected prospectively. All patients underwent a standard spinal cord protection protocol, including routine cerebrospinal fluid drainage. In July 2016, an insulin infusion protocol (IIP) was initiated to maintain postoperative blood glucose levels <120 mg/dL for 48 hours. The primary clinical end point was postoperative SCI.

RESULTS

10 (16%) patients developed postoperative SCI: 6 with transient paraparesis, 2 with persistent paraparesis, and 2 with persistent paraplegia. Patients with SCI were older, had higher shaggy scores, and were less likely to have been on an IIP. There were no significant differences in demographics, aneurysm type, or operative parameters. In a logistic multivariate regression model for SCI, age (odds ratio [OR]: 1.2 [1.1-1.4], P = .02) and shaggy score (OR: 1.2 [1.1-1.4], P = .02) were independently associated with increased risk of SCI, whereas treatment with the IIP was associated with lower risk of SCI (OR: 0.04 [0.006-0.50], P = .05). Of the individual components of the shaggy score, higher descending thoracic aortic ulcer scores were the most strongly associated with postoperative SCI (P = .009).

CONCLUSIONS

Preoperative characterization of aortic wall thrombus is an important adjunctive tool for individualized clinical decision-making and patient counseling about the risk of SCI after BEVAR.

Five-year outcomes of the Bi- versus Trimodular EndurantTM stent-graft in 100 patients with infrarenal abdominal aortic repair

BACKGROUND

Recent studies on the Endurant™ endografts mainly compared outcomes of the bimodular stent-graft to other manufacturer's endografts or reported results for cases outside manufacturer's instructions for use (IFU), while data on the experience of standard endovascular aortic repair (EVAR) of infrarenal abdominal aortic aneurysms (AAA) inside manufacturer's IFU comparing the bi- with the trimodular device is limited.

METHODS

Inclusion criteria were: 1) infrarenal aneurysms (>50 mm diameter) treated by Endurant^TM II (END II) or Endurant^TM IIs (END IIs) stent-graft inside manufacturer's IFU; 2) available CTA with 1 mm reconstruction of the entire aorta prior to intervention. Endpoints comparing the devices included technical success, 30-day mortality, rate of complications (bleeding with conversion to open repair, stent-graft stenosis/occlusion, acute distal embolism, infection or postprocedural necessity of dialysis), endoleaks and reinterventions (5-year follow-up). Aneurysm sac diameters were compared between baseline preinterventional CTA and last post-interventional CTA.

RESULTS

One hundred patients (90% male, mean age 74 years) treated with END II (N.=66) or END IIs (N.=34) were included. Technical success was 99%. One procedure-related active bleeding occurred ending up in surgical conversion (END II N.=1). 30d mortality was 0%. No initial type I/III endoleaks were present. Re-interventions were required in 19/100 (19%) of patients (END II N.=10; END IIs N.=9, P=0.17). The outcome of EVAR including technical success, 30d mortality, rate of complications, endoleaks and re-interventions showed no significant differences comparing END II/IIs.

CONCLUSIONS

Five-year outcomes of EVAR show consistently safe and effective results for either END II or IIs device.

The Shaggy Aorta Syndrome: An Updated Review

BACKGROUND

Shaggy aorta (SA) depicts the severe aortic surface degeneration, extremely friable, and likely to cause spontaneous peripheral and visceral embolization or during catheterization, aortic manipulation, surgery, or minimally invasive procedures. This study aims to provide the most accurate and up-to-date information on this disease.

METHODS

Potentially eligible studies to be included were identified by searching the following databases: CENTRAL Library, ClinicalTrials.gov, MEDLINE, and CINAHL, using a combination of subject headings and text words to identify relevant studies: (Shaggy aorta) OR (aortic embolization) OR (aortic embolism) OR (aortic thrombus) OR (aortic plaque). From a total of 29,111 abstracts, and after applying inclusion and exclusion criteria, we considered 60 studies for inclusion in this review.

RESULTS

Appropriate measurement and assessment of the aortic wall are pivotal in the modern era, in particular when percutaneous procedures are performed, as SA has been identified as an independent risk factor for spinal cord injury, mesenteric embolization, and cerebral infarction after endovascular aortic repair. Furthermore, SA increases the rate of cerebral complications during transcatheter aortic valve implantation.

CONCLUSIONS

In conclusion, prompt diagnosis of SA syndrome and appropriate guidelines on the management of these conditions may help physicians to better assess the patient risk and to minimize the dreadful-related complications.

Gastric remnant necrosis secondary to cholesterol crystal embolization after distal gastrectomy in a gastric cancer patient: a case report

Background

Distal gastrectomy with lymph node dissection, a standard operative technique for gastric cancer treatment, is safely performed because the stomach has a rich vascular supply. Gastric remnant necrosis caused by cholesterol crystal embolization following distal gastrectomy has not been described previously. We report a case of gastric remnant necrosis in a patient with cholesterol crystal embolization.

Case presentation

A 70-year-old man with a history of cholesterol crystal embolization presented to our surgery department with complaints of anorexia and dysphasia. He was diagnosed with gastric cancer invading the pyloric antrum and underwent distal gastrectomy with Billroth 2 reconstruction. On postoperative day 11, he developed abdominal pain without fever. Emergency laparotomy revealed that most parts of the remnant stomach were necrosed. Total gastrectomy with Roux-en-Y reconstruction and abscess drainage were performed. After surgery, anastomotic leakage occurred and was treated conservatively. However, the superior pancreaticoduodenal artery aneurysm suddenly ruptured and he expired.

Conclusions

Gastric remnant necrosis after distal gastrectomy can be a gastrointestinal presentation of cholesterol crystal embolization. Perioperative/intraoperative risk assessments such as preventive total gastrectomy or intraoperative assessment with indocyanine green fluorescence angiography may be desirable to avoid this complication.

Acute Testicular Ischaemia Following Endovascular Aneurysm Repair on the Opposite Side to Intentional Internal Iliac Artery Occlusion

Introduction

Testicular ischaemia is a potential complication after endovascular aneurysm repair (EVAR), which has only rarely been reported in the literature. This is the report of a patient who presented with acute testicular ischaemia in the immediate post-EVAR period.

Report

A 65 year old patient underwent EVAR for an aortic and bilateral iliac aneurysms. During the procedure, the right internal iliac artery was intentionally occluded to facilitate treatment of the common iliac aneurysm; however, the left internal iliac artery was preserved. The procedure was uneventful. On the second post-operative day the patient gradually developed symptoms of acute left testicular ischaemia. Clinical and ultrasonographic findings constituted the bases of diagnosis and the patient received conservative treatment with gradual improvement. To the authors’ knowledge, this is the ninth case of testicular ischaemia after endovascular aneurysm repair reported in the literature.

Conclusion

Testicular ischaemia, although rare, is a possible complication post-EVAR. Acute and chronic testicular damage found in association with an abdominal aortic aneurysm or its treatment has not been well studied in the literature and therefore may be under reported.

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Acute testicular ischaemia, although rare, may occur in the immediate post-EVAR period.

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Changes in testicular perfusion caused by AAA and/or EVAR are not well understood and may be under-reported.

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Distal embolisation or inflow compromise are two possible mechanisms that may result in testicular infarction after EVAR.

Ischemic colitis following infrarenal abdominal aortic aneurysm treatment: Results from a tertiary medical center

OBJECTIVE

The aim of this study was to investigate the effects of ruptured aneurysm on morbidity and mortality in patients with ischemic colitis (IC) and resection following infrarenal abdominal aortic aneurysms (AAA) surgery.

METHODS

Between January 2012 and December 2016, patients who underwent resection for ischemic colitis in our clinic were retrospectively reviewed. Data on the ruptured condition of the aneurysm, the emergency or elective form of aneurysm surgery, treatment method for the aneurysm (EVAR-open) were obtained. The patients were compared and divided into two groups as those with ruptured aneurysm and those without.

RESULTS

A total of 275 infrarenal AAA cases were treated by the cardiovascular surgery clinic between January 2012 and December 2016. Fourteen patients (5%) developed ischemic colitis requiring resection. Four (1.8%) patients with EVAR and 10 (17.5%) patients with open surgery were operated because of IC. No statistically significant difference was observed between the two groups in terms of demographic data and surgical procedures. The intergroup comparison did not reveal any statistically significant difference among gastrointestinal (GIS) symptoms, the time period until surgery, the involved colon segment, and the surgical procedures performed. The mortality rate in ruptured AAA group was 83.3%, while it was 62.5% in the non-ruptured AAA group. In spite of the fact that the mortality rate was high in the ruptured group, it was not statistically significant (p=0.393).

CONCLUSION

IC is a complication of AAA surgery with a high mortality rate. Rupture in abdominal aortic aneurysm increasing mortality in IC patients. This complication with a high mortality rate following open AAA surgery should be noted by surgeons and we believe that the liberal utilization of laparotomy and early intervention in suspected cases will decrease mortality rates.

A case of anastomotic stenosis of the small intestine caused by cholesterol crystal embolism

Background

Cholesterol crystal embolism (CCE) is caused by small crystals of cholesterol dispersed from atherosclerotic plaques of the aorta. There is an increasing interest in CCE because of the increased use of endovascular treatments. Here, we report a rare case of intestinal stenosis caused by CCE after functional end-to-end anastomosis (FEEA). To our knowledge, this is the first report of CCE causing such an anastomotic stenosis.

Case presentation

A 77-year-old male patient underwent laparoscopy-assisted low anterior resection and protective ileostomy for rectal carcinoid tumor. He was admitted to our hospital with ileus 1 year after stoma closure. Eosinophils and creatine kinase level were slightly elevated. Computed tomography revealed a stricture with thickened intestinal wall just distal to the anastomosis site of the ileostomy. The wall of the descending aorta appeared shaggy due to thrombosis. The patient underwent laparoscopic small-bowel resection because ileus reoccurred after any oral intake.

Histopathological findings of the resected specimen showed fibrotic changes distal to the anastomosis site, and needle-shaped cholesterol embolus was observed in the submucosal layer. Thus, the stenosis was considered to be caused by CCE.

Conclusion

This appears to be the first published report of stenosis due to CCE at such an anastomotic site. Intestinal CCE is difficult to diagnose preoperatively and is associated with poor prognosis. If eosinophilia is present or shaggy aorta is observed, CCE should be suspected to make correct diagnosis and prevent recurrence of CCE.

Assessment of aortic wall thrombus predicts outcomes of endovascular repair of complex aortic aneurysms using fenestrated and branched endografts

OBJECTIVE

The goal of this study was to investigate the correlation between atherothrombotic aortic wall thrombus (AWT) and clinical outcomes in patients treated by fenestrated-branched endovascular aortic repair (F-BEVAR) and present a new classification system for assessment of AWT burden.

METHODS

The clinical data of 301 patients treated for pararenal and thoracoabdominal aortic aneurysms (TAAAs) by F-BEVAR was reviewed. The study excluded 89 patients with extent I to III TAAA because of extensive laminated thrombus within the aneurysm sac. Computed tomography angiograms were analyzed in all patients to determine the location, extent, and severity of atherothrombotic AWT. The aorta was divided into three segments: ascending and arch (A), thoracic (B) and renal-mesenteric (C). Volumetric measurements (cm³) of AWT were performed using TeraRecon software (TeraRecon Inc, Foster City, Calif). These volumes were used to create an AWT index by dividing the AWT volume from the total aortic volume. A classification system was proposed using objective assessment of the number of affected segments, thrombus type, thickness, area, and circumference. Clinical outcomes included 30-day mortality, neurologic and gastrointestinal complications, renal events (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease [RIFLE]), and solid organ infarction.

RESULTS

The study included 212 patients, 169 men (80%) and 43 women (20%), with a mean age of 76 ± 7 years. A total of 700 renal-mesenteric arteries were incorporated (3.1 ± 1 vessels/patient). AWT was classified as mild in 98 patients (46%) and was considered moderate or severe in 114 (54%). There was one death (0.5%) at 30 days. Solid organ infarction was present in 50 patients (24%), and acute kidney injury occurred in 45 patients (21%) by RIFLE criteria. An association with higher AWT indices was found for time to resume enteral diet (P = .0004) and decline in renal function (P = .0003). Patients with acute kidney injury 2 by RIFLE criterion had significantly higher (P = .002) AWT index scores in segment B. Spinal cord injury occurred in three patients (1.4%) and stroke in four (1.9%), but were not associated with the AWT index. Severity of AWT using the new proposed classification system correlated with the AWT index in all three segments (P < .001). Any of the end points occurred in 35% of the patients with mild and in 53% of those with moderate or severe AWT (P = .016).

CONCLUSIONS

AWT predicts solid organ infarction, renal function deterioration, and longer time to resume enteral diet after F-BEVAR of pararenal and type IV TAAAs. Evaluation of AWT should be part of preoperative planning and decision making for selection of the ideal method of treatment in these patients.

Exploring inside a shaggy aorta using non-obstructive angioscopy

A shaggy aorta is reportedly related to atheromatous embolisation, which causes serious ischaemic damage to various organs. However, its characteristics are poorly understood. Non-obstructive angioscopy (NOA) has been developed to safely detect aortic plaques and injuries. A 70-year-old woman who was found to have a shaggy aorta on CT angiography underwent NOA for precise evaluation of vulnerable aortic plaques and injuries inside the aorta. Vulnerable aortic plaques included puff-like ruptures, chandelier-like ruptures and erosions seen throughout the aorta. Aortic injuries included flaps, slits, subintimal bleeding, dissection and multilayered partitions. The patient had no embolic symptoms or an elevated eosinophil count, estimated glomerular filtration rate or C reactive protein level, compared with the baseline. Various changes in spontaneous vulnerable plaques and injuries inside the aorta that were not apparent on CT were safely revealed on NOA. Thus, NOA may reveal findings indicative of spontaneous and postoperative atheromatous embolisation.

Acute Global Testicular Infarction Post-EVAR from Cholesterol Embolisation can be Mistaken for Torsion

Introduction

Endovascular aneurysm repair (EVAR) is the most commonly used approach for treatment of abdominal aortic aneurysms (AAA). Testicular infarction is a rare complication of EVAR. A novel case of acute global testicular infarction post-EVAR from cholesterol embolisation mimicking torsion is presented.

Report

A 75 year old man developed acute right testicular ischaemia requiring orchidectomy following EVAR of an infrarenal aortic aneurysm. The patient was initially diagnosed with testicular torsion as the aetiology of the infarction; however, on re-analysis of histopathology it was found to be secondary to cholesterol emboli.

Discussion

In patients complaining of groin/scrotal pain following EVAR, it is worth considering testicular ischaemia whether secondary to cholesterol embolisation or gonadal occlusion. Clinicians should be aware that clinical and radiological findings can mimic torsion as this affects management and outcome.

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Endovascular aneurysm repair (EVAR) is the most commonly used approach for repair of abdominal aortic aneurysms.

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Testicular ischaemia is a rare complication of EVAR.

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Clinical and radiological findings may mimic testicular torsion.

Débridement of atheroma in the proximal clamp site under hypothermic circulatory arrest for repair of abdominal aortic aneurysm with severe atherosclerosis

Postoperative renal and other ischemic complications due to atheroembolization after clamping of the proximal site of an abdominal aortic aneurysm are catastrophic. We present here a method of débridement of atheroma and clamping under hypothermic circulatory arrest to avoid iatrogenic atheroembolization.

Risk factors for ischaemic colitis after surgery for abdominal aortic aneurysm: a systematic review and observational meta-analysis

BACKGROUND

Ischaemic colitis is an infrequent but serious complication following repair of abdominal aortic aneurysm (AAA), with high mortality rates. This systematic review set out to identify risk factors for the development of ischaemic colitis after AAA surgery.

METHODS

A systematic search of the MEDLINE, EMBASE and CINAHL databases was performed. This search was limited to studies published in the English language after 1990. Abstracts were screened by two authors. Eligible studies were obtained as full text for further examination. Data was extracted by two authors, and any disputes were resolved via consensus. Extracted data was pooled using Mantel-Haenszel random effects models. Bias was assessed using two Cochrane-approved tools. Effect sizes are expressed as relative risk ratios alongside the 95 % confidence interval. Statistical significance was defined at the level of p < 0.05.

RESULTS

From 388 studies identified in the initial search, 33 articles were included in the final synthesis and analysis. Risk factors were grouped into patient (female gender, disease severity) and operative factors (peri-procedural hypotension, operative modality). The risk of ischaemic colitis was significantly higher when undergoing emergency repair versus elective (risk ratio (RR) 7.36, 3.08 to 17.58, p < 0.001). Endovascular repair reduced the likelihood of ischaemic colitis (RR 0.22, 0.12 to 0.39, p < 0.001).

DISCUSSION

The quality of published evidence on this subject is poor with many retrospective datasets and inconsistent reporting across studies. Despite this, emergency presentation and open repair should prompt close monitoring for the development of IC.

Risk factors for early renal dysfunction following endovascular aortic aneurysm repair and its effect on the postoperative outcome

PURPOSE

Renal insufficiency is associated with increased morbidity and death after endovascular aortic aneurysm repair (EVAR). However, the effect of postoperative acute kidney dysfunction on patient outcome has not been fully determined. This study aimed to determine the risk factors of early postoperative renal function decline using chronic kidney disease (CKD) staging and its effect on the clinical outcome.

METHODS

A retrospective analysis was performed on a prospectively maintained EVAR database. Pre- and postoperative CKD stages were determined for all patients according to the estimated glomerular filtration rate values.

RESULTS

We identified 135 patients who were treated with elective EVAR. CKD stage decline was observed in 25 (19 %) of the patients. Freedom from aneurysm-related death was significantly lower in patients with postoperative CKD progression compared with those with unchanged CKD stage. A shaggy aorta without oral beta-blocker administration and higher preoperative serum creatinine levels (>1.4 mg/dL) were found to be independent predictors of an early postoperative CKD stage decline.

CONCLUSIONS

Patients with postoperative CKD progression have an increased frequency of aneurysm-related death. The presence of a shaggy aorta, absence of oral beta-blocker administration and an increased preoperative creatinine level are independent predictors of early postoperative CKD progression.

Quantified Aortic Luminal Irregularity as a Predictor of Complications and Prognosis After Endovascular Aneurysm Repair

Atheromatous degeneration of the aorta is considered to be a risk factor for postoperative embolic complications after endovascular treatment, and is associated with a high incidence of vascular events in the long term. We devised a method to quantify the shagginess of the aorta using contrast-enhanced computed tomography (CT) images. This study examined the method's validity and prognostic usefulness in patients undergoing elective endovascular abdominal aortic aneurysm repair (EVAR). We retrospectively investigated 427 patients who underwent elective EVAR between 2007 and 2013. Preoperative contrast-enhanced CT images with a slice thickness of 1 mm were analyzed using a workstation, and the degree of aortic luminal irregularity from the level of the left subclavian artery ostium to that of the celiac artery ostium was quantified by computing a shagginess score. We compared the computed scores with subjective visual assessments of aortic shagginess. Subsequently, we evaluated the relationship between the computed scores and postoperative prognosis. The shagginess scores were significantly correlated with the visual assessments of the aortic lumen, which were performed by 5 experienced vascular surgeons (rho ranged from 0.564-0.654, all P < 0.001). Multiple logistic regression analysis demonstrated that the shagginess score was independently associated with the development of renal impairment within a month after EVAR (odds ratio, 2.78; 95% confidence interval [CI], 1.83-4.22, P < 0.001). The shagginess score was significantly higher in patients who suffered postoperative intestinal and peripheral ischemic complications, as compared with those who did not (P < 0.001). The mean postoperative follow-up period was 1207 ± 641 days. Cox proportional hazards regression showed that the shagginess score was a significant independent predictor of all-cause and cardiovascular mortality (hazard ratio [HR], 1.37; 95% CI, 1.09-1.72, P = 0.007, and HR, 1.51; 95% CI, 1.04-2.18, P = 0.030, respectively). The results suggest that the shagginess score provides a quantitative reflection of aortic luminal irregularity. It may serve as a useful predictive factor for postoperative renal function deterioration, embolic complications, and long-term mortality after elective EVAR.