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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.
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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.
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Dinc R, Ardic N. Role of Potential Biomarkers in Aortic Aneurysms: Does It Hold Promise for Clinical Decision Making? Ann Vasc Surg 2025; 110:349-352. [PMID: 39413998 DOI: 10.1016/j.avsg.2024.07.128] [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: 07/18/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 10/18/2024]
Abstract
Aortic aneurysms (AAs) are a life-threatening disease with a mortality rate of up to 80% when they rupture. AA has a multifactorial etiology, including smoking, advanced age, and family history, and has multifaceted pathophysiological mechanisms underlying its formation, mainly including inflammation of the aortic wall, reduction of medial smooth muscle cells, and degradation of the extracellular matrix. It is also a progressive disease. Their treatments are limited to open surgical repair and endovascular aneurysm repair. There is no effective drug treatment. The diagnosis of AA is usually made as a result of a scan performed for another reason. There is no specific diagnostic and prognostic biomarker available, and great efforts are being made on this subject. These studies reveal that in the future, the causal pathophysiological mechanisms for the occurrence and progression of AA will be elucidated and some potential biomarkers will be adopted to facilitate clinical decision-making. This commentary provides a brief contribution to Teng et al.'s analysis of the causal influence between AA and immune-metabolic interactions, and eventually identification of biomarkers.
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Affiliation(s)
- Rasit Dinc
- INVAMED Medical Innovation Institute, Ankara, Turkey
| | - Nurittin Ardic
- Med-International UK Health Agency Ltd, Leicestershire, UK.
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de Athayde Soares R, Portela MVV, Amaro K, Nasser AI, Pedrosa KDL, Sacilotto R. The Enzen Trial: Analysis of EVAR Endoprosthesis Zenith and Endurant for Infrarenal Aortoiliac Aneurysms Regarding Outcomes, Endoleaks, and Reinterventions. J Endovasc Ther 2024:15266028241270895. [PMID: 39183689 DOI: 10.1177/15266028241270895] [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: 08/27/2024]
Abstract
OBJECTIVE The main objective of this paper is to analyze the outcomes regarding endoleaks, reinterventions, and death related to aneurysm complications in patients submitted to endovascular repair (EVAR) for abdominal aortoiliac aneurysm (AAA) using Endurant II (Medtronic) and Zenith Flex (Cook) endografts. METHODS This was a prospective, consecutive cohort study of patients with AAA who underwent EVAR between January 2019 and December 2022. Two groups of patients were evaluated: Group Endurant (patients submitted to EVAR with the use of Endurant II) and Group Zenith (patients submitted to EVAR with the use of Zenith Flex). RESULTS A total of 156 patients were evaluated. Group Zenith (67 patients, 42.9%) and Group Endurant (89 patients, 57.1%). The perioperative mortality was 5.1%, eight patients (six patients Group Zenith, and two patients Group Endurant, p=0.054). There were 28 patients (17.9%) submitted to urgent repair of the aneurysm (expansion or rupture), with no differences among the groups. There were 36 cases (23.1%) of later endoleak, with a higher incidence in Zenith group (23 patients, 34.3%) than Endurant group (13 patients, 14.6%, p=0.002), most of them Type II endoleak (21 patients, 13.4%). There were 12 cases of Type I endoleak, also with a higher prevalence in Zenith group (13.4%) than Endurant group (3.4%, p=0.002). Moreover, regarding limb graft occlusion (LGO), there were nine patients (5.8%), with a higher prevalence in Zenith group (9%) than Endurant group (3.4%, p=0.045). The overall survival in a Kaplan-Meier at 720 days was 82.3% in the Zenith group and 89.1% in the Endurant group, with no statistical significance among the groups (p=0.09). The freedom from reintervention rates in a Kaplan-Meier at 720 days was 82.8% in the Zenith group and 93.2% in the Endurant group (p=0.001). CONCLUSION In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, LGO and reinterventions than patients submitted to Endurant II endografts. The linear regression analysis showed that the presence of endoleaks, type of endograft device (Zenith graft) and limb graft occlusion were related to higher reintervention rates. CLINICAL IMPACT In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, limb graft occlusions and reinterventions than patients submitted to Endurant II endografts. The main impact and the innovation that this article provides is an opportunity to evaluate and choose the best endograft suitable for the patient with AAA during EVAR.
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Affiliation(s)
- Rafael de Athayde Soares
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Matheus Veras Viana Portela
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Kaline Amaro
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Ana Izabel Nasser
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Keityane de Lima Pedrosa
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Roberto Sacilotto
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
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Soares RDA, Amaro K, Nasser AI, Cury MVM, Nakamura ET, Pedrosa KDL, Sacilotto R. Endovascular repair for infra-renal aortic aneurysms with supra-renal fixation endoprosthesis: Results and outcomes. Vascular 2024:17085381241264381. [PMID: 39030072 DOI: 10.1177/17085381241264381] [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: 07/21/2024]
Abstract
OBJECTIVE The main objective of this paper is to evaluate the outcomes regarding endoleaks, reinterventions, and death related to aneurysm complications in patients submitted to endovascular repair (EVAR) for abdominal aortoiliac aneurysm (AAA) using Endurant II (Medtronic) and Zenith Flex (Cook) endografts. METHODS This was a prospective, consecutive cohort study of patients with AAA who underwent EVAR with the use of Endurant II stent graft and Zenith Flex endograft. RESULTS A total of 156 patients submitted to EVAR were evaluated. The perioperative mortality was 5.1%, 8 patients. The median clinical follow-up period was 760 ± 80 days. There were 28 patients (17.9%) submitted to urgent repair of the aneurysm (symptomatic expansion or rupture) and 128 patients (82.1%) submitted to elective repair. There were 36 cases (23.1%) of later endoleak and most of them are Type II endoleaks (21 patients, 13.4%). There were 12 cases of Type I endoleak. Moreover, regarding limb graft occlusion (LGO), there were 9 patients (5.8%). The overall survival rate in Kaplan-Meier analysis at 720 days was 84.8% in the total cohort. The freedom from reintervention rate in Kaplan-Meier analysis at 720 days was 92.7% in the total cohort. The linear regression analysis for survival rates showed that chronic kidney disease (p = .03; hazard ratio (HR) = 2.82, CI = 1.07-4.44) was the only factor related to poorer survival rates in both univariate and multivariate analyses. The linear regression analysis showed that the presence of endoleaks (p < .001, HR = 6.69, CI = 2.26-8.48) and limb graft occlusion (p < .001, HR = 8.02, CI = 1.60-9.99) were related to reintervention in both univariate and multivariate analyses. CONCLUSION In this present study, supra-renal fixation endograft devices were safe and efficient in treating AAA, with satisfactory results and no renal compromise. The linear regression analysis showed that the presence of endoleaks and limb graft occlusion were related to higher reintervention rates in both univariate and multivariate analyses.
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Affiliation(s)
- Rafael de Athayde Soares
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Kaline Amaro
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Ana Isabel Nasser
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Marcus Vinícius Martins Cury
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Edson Takamitsu Nakamura
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Keityane de Lima Pedrosa
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Roberto Sacilotto
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
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Kuijpers M, Holewijn S, Blankensteijn JD, Reijnen MMPJ. Prevalence of type II endoleak after elective endovascular aneurysm repair with polytetrafluoroethylene- or polyester-based endografts. J Vasc Surg 2024; 79:24-33. [PMID: 37734570 DOI: 10.1016/j.jvs.2023.09.019] [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: 06/27/2023] [Revised: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE Type II endoleak is the most frequent complication after endovascular abdominal aneurysm repair. Polytetrafluoroethylene and polyester (PE) are the two most commonly used graft materials in endovascular aneurysm repair (EVAR) devices. Biological properties of the material might influence the appearance and persistence of type II endoleak (T2EL). Therefore, the aim of this study was to evaluate potential differences in the prevalence of T2EL after EVAR between polytetrafluoroethylene (PTFE) and PE endografts in patients electively treated for an infrarenal abdominal aortic aneurysm. METHODS A single-center, retrospective, observational study was conducted between January 2011 and January 2022. Preoperative, procedural, and follow-up data were derived from electronic health records. Imaging included computed tomography scans, and/or duplex ultrasound examination. The primary end point was the prevalence of T2EL diagnosed within 1 year after EVAR. Secondary end points included the prevalence of T2EL throughout follow-up, early (≤30 days) and late (>30 days) T2EL, the rate of T2EL disappearance during the follow-up period, the prevalence of type I and III endoleak, and T2EL-related reinterventions. RESULTS Follow-up was available for 394 patients, 245 in the PE and 149 in the PTFE group. The prevalence of T2EL diagnosed within 1 year after endovascular repair was 11.8% in the PE group and 21.5% in the PTFE group (P = .010). There was no significant difference in early (≤30 days) and late (>30 days) T2EL between groups (P = .270 and P = .311). There was no difference in the freedom from endoleak type II reinterventions between groups (P = .877). CONCLUSIONS The prevalence of T2EL after elective EVAR is significantly higher with the use of PTFE-based endografts compared with PE-based endografts. This difference is mostly based on T2EL diagnosed after 30 days of follow-up.
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Affiliation(s)
- Maud Kuijpers
- Department of Surgery, Rijnstate, Arnhem, the Netherlands
| | | | | | - Michel M P J Reijnen
- Department of Surgery, Rijnstate, Arnhem, the Netherlands; Multi-Modality Medical Imaging Group, TechMed Center, University of Twente, Enschede, the Netherlands.
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Väärämäki S, Uurto I, Suominen V. Possible implications of device-specific variability in post-endovascular aneurysm repair sac regression and endoleaks for surveillance categorization. J Vasc Surg 2023; 78:1204-1211. [PMID: 37451372 DOI: 10.1016/j.jvs.2023.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/07/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Significant sac regression during early surveillance has been shown to best predict reintervention-free long-term surveillance after endovascular aneurysm repair (EVAR). Furthermore, a persistent endoleak has been related to a worse outcome. Individualized surveillance algorithms based on these findings have been suggested. There are no studies comparing the performance of different stent grafts regarding sac regression, the presence of type II endoleaks, and their possible implications for individualized surveillance. The objective of this study was to evaluate device-specific differences and how these may affect patient categorization for surveillance. METHODS Patients were treated electively with standard EVAR between 2005 and 2015 using three different devices (Zenith by Cook, Excluder by Gore, and Endurant by Medtronic). The data were reviewed retrospectively until 2020. Patients' computed tomography angiographies (CTAs) at 30 days and at 2 years were analyzed for freedom from endoleaks and for sac regression of ≥5 mm. Reinterventions during long-term surveillance were counted. Patients were categorized according to the presence of any endoleak and sac regression at 30 days and 2 years, and the probability of reintervention-free long-term surveillance was evaluated based on these findings. RESULTS A total of 435 patients were treated for an abdominal aortic aneurysm with EVAR during the study period. At 30 days, 80.0% (n = 339) of the patients were free from endoleaks, and at 2 years, 78.9% (n = 273) were free from endoleaks. There was a significant difference in endoleak rate at 30 days and 2 years between the devices (P < .001 and P = .001). There was no significant difference in sac regression between the devices at 2 years (P = .096). The categorization at 30 days based on endoleak status had a sensitivity of 44.9%, specificity of 87.4%, and negative predictive value of 84.1% for finding a reintervention-requiring complication during long-term follow-up. The corresponding figures at 2 years were 63.3%, 91.4%, and 89.4%, respectively. The combination of freedom from endoleaks and sac regression of ≥5 mm in the 2-year CTA best predicted an uneventful long-term surveillance. Patients who met this criterion had a 95.6% probability (negative predictive value) of having a reintervention-free long-term surveillance. CONCLUSIONS There are significant differences in the prevalence of endoleaks between devices at 30 days and 2 years, but there is no difference in sac regression. Patients with sac regression of ≥5 mm and no endoleaks in the 2-year CTA can be safely categorized for infrequent surveillance regardless of the stent graft model that has initially been used.
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Affiliation(s)
- Suvi Väärämäki
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, and Tampere University, Faculty of Medicine and Life Sciences, Tampere, Finland.
| | - Ilkka Uurto
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, and Tampere University, Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Velipekka Suominen
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, and Tampere University, Faculty of Medicine and Life Sciences, Tampere, Finland
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Jubouri M, Surkhi AO, Tan SZCP, Bailey DM, Williams IM. Patient longevity and survival with custom-made endovascular solutions: The Fenestrated Anaconda TM approach. Asian Cardiovasc Thorac Ann 2023; 31:615-623. [PMID: 36803010 DOI: 10.1177/02184923231158579] [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: 02/23/2023]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) has become the mainstay treatment for abdominal aortic aneurysms and is associated with excellent clinical outcomes. However, there remains a risk of complications requiring reintervention. Several EVAR devices exist commercially, yet, the Terumo Aortic Fenestrated Anaconda™ has demonstrated outstanding results. The main scope of this study is to evaluate survival/longevity, target vessel patency (TVP), endograft migration and reintervention following Fenestrated Anaconda™ implantation and discuss relevant literature. METHODS The current study represents a 9-year cross-sectional international analysis of custom-made Fenestrated Anaconda™ device. For the statistical analysis, SPSS 28 for Windows and R was utilised. Pearson Chi-Square analysis was used to assess differences in cumulative distribution frequencies between variables. Statistical significance for all two-tailed tests was set at p < 0.05. RESULTS A total of 5058 patients received the Fenestrated Anaconda™ endograft. The Fenestrated Anaconda™ was indicated either due to complex anatomy for competitor devices (n = 3891, 76.9%) or based on surgeon preference (n = 1167, 23.1%). Both survival and TVP were 100% during the first 6 postoperative years but dropped to 77.1% and 81% thereafter. In the complex anatomy indication group, cumulative survival and TVP were both 100% until year 7 post-EVAR when they decreased to 82.8% and 75.7%. In the other indication group, survival and TVP were also 100% during the first 6 years but plateaued at 58.1% and 98.8% in years 7-9 of follow-up. No cases of endograft migration and reintervention were recorded. CONCLUSION The Fenestrated Anaconda™ has been proven across the literature to be a highly effective EVAR endograft, as it has demonstrated excellent survival/longevity and TVP as well as minimal endograft migration and reintervention.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | | | - Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Cardiff, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
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Jubouri M, Surkhi AO, Tan SZ, Bailey DM, Williams IM, Bashir M. Correlative effect between sac regression and patient longevity following endovascular solution for abdominal aortic aneurysms: an international analysis. Asian Cardiovasc Thorac Ann 2023; 31:557-564. [PMID: 36168205 DOI: 10.1177/02184923221129983] [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: 11/15/2022]
Abstract
INTRODUCTION Since the introduction of endovascular aortic repair (EVAR) it has become the mainstay treatment for abdominal aortic aneurysms. Several EVAR devices exist commercially, yet, the Terumo Aortic Fenestrated Anaconda™ endograft has demonstrated outstanding results. Evidence in the literature suggests that sac regression could be linked to patient survival and longevity. The main scope of this study is to evaluate sac regression and survival achieved using the Fenestrated Anaconda™ endograft and to discuss relevant literature. MATERIALS AND METHODS The current study represents a nine-year cross-sectional international analysis of custom-made Fenestrated Anaconda™ device. For the statistical analysis, SPSS 28 for Windows and R were utilised. Pearson chi-square analysis was used to assess differences in cumulative distribution frequencies between select variables. Statistical significance for all two-tailed tests was set at p < 0.05. RESULTS A total of 5,058 patients received the Fenestrated Anaconda™ in this study, either due to unsuitable/complex anatomy for competitor devices (n = 3,891) or based on surgeon preference (n = 1,167). A sac regression of 0-30% was observed in 4,772 (94.3%) over the first four years post-EVAR. Here, 99.6% of patients receiving the Fenestrated Anaconda™ due to unsuitable/complex anatomy for competitor devices and 76.8% based on surgeon preference had 0-30% sac regression. During years 5-9 of follow-up, all patients had 20-45% sac regression. Patient survival during the first six years post-EVAR was 100% but dropped to 77.1% in years 7-9. Survival differed between categorical patient subsets based on the indication. DISCUSSION The Fenestrated Anaconda™ has been proven to be a highly effective EVAR endograft. Evidence in the literature clearly demonstrates that sac regression is an accurate prognostic factor for patient survival and longevity.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | | | - Sven Zcp Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Wales, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Wales, UK
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales (HEIW), Cardiff, UK
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Jubouri M, Hussain K, Saha P, Alkhadire ZM, Tan SZ, Bailey DM, Williams IM, Bashir M. Endovascular solutions for abdominal aortic aneurysms: A comparative review of clinical outcomes with custom-made endografts. Asian Cardiovasc Thorac Ann 2023; 31:565-576. [PMID: 36299237 DOI: 10.1177/02184923221133956] [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: 06/16/2023]
Abstract
BACKGROUND The introduction of endovascular aortic repair has revolutionised the treatment of abdominal aortic aneurysms, replacing open surgical repair for the majority of elective cases due to its optimal morbidity and mortality. Several endovascular aortic repair stent grafts exist commercially, one of which is the Fenestrated Anaconda™ by Terumo Aortic which benefits from a very innovative design, unique custom-made approach and highly favourable results. AIMS The main scope of this narrative review is to provide a comprehensive overview of endovascular aortic repair clinical outcomes using the Fenestrated Anaconda™ stent-graft and comparing these with its market competitor, Zenith. This review will also examine the evidence in the literature on the Anaconda™'s custom-made approach. METHODS A comprehensive literature was conducted on several search engines including PubMed, Google Scholar, Ovid, Scopus and Embase to collate the evidence in the literature on clinical outcomes achieved with the Fenestrated Anaconda™ and Zenith including, but not limited to, survival, technical success, target vessel patency, endoleak, reintervention and aneurysm sac regression. RESULTS The Fenestrated Anaconda™ is associated with excellent results, including highly favourable survival, technical and clinical success and target vessel patency rates, very low need for reintervention or conversion, and minimal incidence of complications such as endoleak and endograft migration. The Fenestrated Anaconda™ also drives significant sac regression and aortic remodelling. In addition, its unique custom-made approach enables it to treat highly complex aortic anatomy as well as to 'rescue' failed competitor grafts. CONCLUSION The Fenestrated Anaconda™ has proven that it is a very safe, highly applicable and extremely effective device used for complex aortic and/or iliac pathology based on its novel design and outstanding track record of clinical outcomes.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Kamran Hussain
- East Lancashire Teaching Hospitals NHS Trust, Blackburn, UK
| | - Priyanshu Saha
- School of Medicine, St George's University of London, London, UK
| | | | - Sven Zcp Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education & Improvement Wales (HEIW), Cardiff, UK
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Jubouri M, Surkhi AO, Tan SZCP, Bailey DM, Williams IM, Bashir M. Abdominal Aortic Aneurysm: Can the Anaconda™ Custom-Made Device Deliver? An International Perspective. Front Cardiovasc Med 2022; 9:959149. [PMID: 35911560 PMCID: PMC9329582 DOI: 10.3389/fcvm.2022.959149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/20/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Since the introduction of endovascular aortic repair (EVAR), it has demonstrated excellent clinical outcomes and has replaced open surgical repair (OSR) in the treatment of abdominal aortic aneurysms (AAA). AAA is a life-threatening abnormal dilation of the abdominal aorta to 1.5 times its normal diameter. Several commercial EVAR devices exist on the global market, with the Terumo Aortic Fenestrated Anaconda™ graft showing superiority. In this study, we sought to provide an international perspective using multicenter-multinational data on the Anaconda™ device characteristics, design, and delivery, and discuss relevant literature. Materials and Methods This study represents a cross-sectional international analysis of custom-made fenestrated Anaconda™ device. Ethical and legal approval for data collection was obtained from each of the local authorities. For the statistical analysis, SPSS 28 for Windows and R were utilized. Pearson’s chi-square analysis was used to assess differences in cumulative distribution frequencies between select variables. Statistical significance for all two-tailed tests was set at p < 0.05. Results A total of 5,030 Anaconda™ devices were implanted during the 9-year study period in 27 countries spanning 6 continents. The predominant device category was bifurcate (83.6%), whereas the most common proximal ring stent configuration being standard (64.5%). All devices were delivered within 8 weeks of diagnosis, with most being implanted within 6–8 weeks (55.4%). The Anaconda™ was indicated in the 3,891 (77.4%) patients due to competitor rejection/inability to treat unsuitable/complex aortic anatomy. In the remaining 1,139 (22.6%) patients, it was utilized based on surgeon preference. Almost all devices (95%) were delivered along with a prototype. Of the total 5,030 Anaconda™ devices, 438 (8.7%) used 0–1 fenestrations, 2,349 (46.7%) used 2–3, while 2,243 (44.6%) utilized 4, 5, or 6 fenestrations. Discussion The Terumo Aortic Fenestrated Anaconda™ device features a highly unique and innovative design that enables it to treat highly complex aortic anatomy while achieving excellent results. The Anaconda™’s custom-made approach allows it to be tailored to individual patient anatomy, in addition to the device prototype provided by Terumo Aortic optimize clinical outcomes. Finally, the fenestrated Anaconda™ is a highly versatile device offering a wide range of device categories, configurations, and sizes.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, United Kingdom
| | | | - Sven Z. C. P. Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Damian M. Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Cardiff, United Kingdom
| | - Ian M. Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Cardiff, United Kingdom
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales (HEIW), Cardiff, United Kingdom
- *Correspondence: Mohamad Bashir,
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Vahabli E, Mann J, Heidari BS, Lawrence‐Brown M, Norman P, Jansen S, De‐Juan‐Pardo E, Doyle B. The Technological Advancement to Engineer Next-Generation Stent-Grafts: Design, Material, and Fabrication Techniques. Adv Healthc Mater 2022; 11:e2200271. [PMID: 35481675 PMCID: PMC11468507 DOI: 10.1002/adhm.202200271] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/04/2022] [Indexed: 12/12/2022]
Abstract
Endovascular treatment of aortic disorders has gained wide acceptance due to reduced physiological burden to the patient compared to open surgery, and ongoing stent-graft evolution has made aortic repair an option for patients with more complex anatomies. To date, commercial stent-grafts are typically developed from established production techniques with simple design structures and limited material ranges. Despite the numerous updated versions of stent-grafts by manufacturers, the reoccurrence of device-related complications raises questions about whether the current manfacturing methods are technically able to eliminate these problems. The technology trend to produce efficient medical devices, including stent-grafts and all similar implants, should eventually change direction to advanced manufacturing techniques. It is expected that through recent advancements, especially the emergence of 4D-printing and smart materials, unprecedented features can be defined for cardiovascular medical implants, like shape change and remote battery-free self-monitoring. 4D-printing technology promises adaptive functionality, a highly desirable feature enabling printed cardiovascular implants to physically transform with time to perform a programmed task. This review provides a thorough assessment of the established technologies for existing stent-grafts and provides technical commentaries on known failure modes. They then discuss the future of advanced technologies and the efforts needed to produce next-generation endovascular implants.
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Affiliation(s)
- Ebrahim Vahabli
- Vascular Engineering LaboratoryHarry Perkins Institute of Medical ResearchQEII Medical CentreNedlands and the UWA Centre for Medical ResearchThe University of Western AustraliaPerth6009Australia
- School of EngineeringThe University of Western AustraliaPerth6009Australia
| | - James Mann
- Vascular Engineering LaboratoryHarry Perkins Institute of Medical ResearchQEII Medical CentreNedlands and the UWA Centre for Medical ResearchThe University of Western AustraliaPerth6009Australia
- School of EngineeringThe University of Western AustraliaPerth6009Australia
| | - Behzad Shiroud Heidari
- Vascular Engineering LaboratoryHarry Perkins Institute of Medical ResearchQEII Medical CentreNedlands and the UWA Centre for Medical ResearchThe University of Western AustraliaPerth6009Australia
- School of EngineeringThe University of Western AustraliaPerth6009Australia
- Australian Research Council Centre for Personalised Therapeutics TechnologiesUniversity of Western AustraliaPerth6009Australia
| | | | - Paul Norman
- Vascular Engineering LaboratoryHarry Perkins Institute of Medical ResearchQEII Medical CentreNedlands and the UWA Centre for Medical ResearchThe University of Western AustraliaPerth6009Australia
- Medical SchoolThe University of Western AustraliaPerth6009Australia
| | - Shirley Jansen
- Curtin Medical SchoolCurtin UniversityPerthWA6102Australia
- Department of Vascular and Endovascular SurgerySir Charles Gairdner HospitalPerthWA6009Australia
- Heart and Vascular Research InstituteHarry Perkins Medical Research InstitutePerthWA6009Australia
| | - Elena De‐Juan‐Pardo
- School of EngineeringThe University of Western AustraliaPerth6009Australia
- T3mPLATEHarry Perkins Institute of Medical ResearchQEII Medical CentreNedlands and the UWA Centre for Medical ResearchThe University of Western AustraliaPerthWA6009Australia
- School of Mechanical, Medical and Process EngineeringQueensland University of TechnologyBrisbaneQueensland4059Australia
| | - Barry Doyle
- Vascular Engineering LaboratoryHarry Perkins Institute of Medical ResearchQEII Medical CentreNedlands and the UWA Centre for Medical ResearchThe University of Western AustraliaPerth6009Australia
- School of EngineeringThe University of Western AustraliaPerth6009Australia
- Australian Research Council Centre for Personalised Therapeutics TechnologiesUniversity of Western AustraliaPerth6009Australia
- British Heart Foundation Centre for Cardiovascular ScienceThe University of EdinburghEdinburghEH16 4TJUK
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12
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Väärämäki S, Uurto I, Hahl T, Suominen V. Reliability and safety of individualized follow-up based on the 30-day CTA after endovascular aneurysm repair (EVAR). Ann Vasc Surg 2022; 86:305-312. [DOI: 10.1016/j.avsg.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 03/02/2022] [Accepted: 04/06/2022] [Indexed: 11/16/2022]
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13
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Editor's Choice - Post-operative Surveillance and Long Term Outcome after Endovascular Aortic Aneurysm Repair in Patients with an Initial Post-operative Computed Tomography Angiogram Without Abnormalities: the Multicentre Retrospective ODYSSEUS Study. Eur J Vasc Endovasc Surg 2022; 63:390-399. [PMID: 35181224 DOI: 10.1016/j.ejvs.2021.11.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 11/01/2021] [Accepted: 11/14/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Lifelong imaging surveillance is recommended following endovascular aneurysm repair (EVAR). This study aimed to examine the association between adherence to post-operative surveillance and survival and secondary interventions in patients with an initial post-operative computed tomography angiogram (CTA) without abnormalities. METHODS All consecutive patients undergoing EVAR for intact abdominal aortic aneurysm (AAA) in 16 hospitals between 2007 and 2012 were identified retrospectively, with follow up until December 2018. Patients were included if the initial post-operative CTA showed no types I - III endoleak, kinking, infection, or limb occlusion. Discontinued follow up was defined as at least one 16 month period in which no imaging surveillance was performed. Primary outcomes were aneurysm related mortality and secondary interventions, and secondary outcome all cause mortality. Kaplan-Meier analysis was used to estimate survival, and Cox regression analyses to identify the association between independent variables and outcome. Sensitivity analyses were performed by varying the definition of continued yearly follow up. The study protocol was published (bmjopen-2019-033584). RESULTS 1 596 patients (552 continued, 1 044 discontinued follow up) were included with a median (interquartile range) follow up of 89.1 months (52.6). Cumulative aneurysm related, overall, and intervention free survival was 99.4/94.8/96.1%, 98.5/72.9/85.9%, and 96.3/45.4/71.1% at 1, 5, and 10 years, respectively. American Society of Anesthesiologists (ASA) classification (ASA IV hazard ratio [HR] 3.810, 95% confidence interval [CI] 1.296 - 11.198), increase in AAA diameter (HR 3.299, 95% CI 1.408 - 7.729), and continued follow up (HR 3.611, 95% CI 1.780 - 7.323) were independently associated with aneurysm related mortality. The same variables and age (HR 1.063 per year, 95% CI 1.052 - 1.074) were significantly associated with all cause mortality. No difference in secondary interventions was observed between patients with continued vs. discontinued follow up (89/552; 16% vs. 136/1044; 13%; p = .091). Sensitivity analyses showed worse aneurysm related and overall survival in patients with continued follow up. CONCLUSION Discontinued follow up is not associated with poor outcomes. Future prospective studies are indicated to determine in which patients imaging follow up can be safely reduced.
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Lieberg J, Kadatski KG, Kals M, Paapstel K, Kals J. Five-year survival after elective open and endovascular aortic aneurysm repair. Scand J Surg 2021; 111:14574969211048707. [PMID: 34779283 DOI: 10.1177/14574969211048707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVE Current evidence suggests short-term survival benefit from endovascular aneurysm repair (EVAR) versus open surgical repair (OSR) in elective abdominal aortic aneurysm (AAA) procedures, but this benefit is lost during long-term follow-up. The aim of this study was to compare short- and mid-term all-cause mortality in patients with non-ruptured aneurysm treated by OSR and EVAR; and to assess the rate of complications and reinterventions, as well as to evaluate their impact on survival. METHODS The medical records of the non-ruptured AAA patients undergoing OSR or EVAR between 1 January 2011 and 31 December 2019 at Tartu University Hospital, Estonia, were retrospectively reviewed. We gathered survival data from the national registry (mean follow-up period was 3.7 ± 2.3 years). RESULTS A total of 225 non-ruptured AAA patients were treated operatively out of whom 95 (42.2%) were EVAR and 130 (57.8%) were OSR procedures. The difference in estimated all-cause mortality between the OSR and EVAR groups at day 30 was statistically irrelevant (2.3% vs 0%; p = 0.140), but OSR patients showed statistically significantly higher 5 year survival compared with EVAR patients (75.3% vs 50.0%, p = 0.002). Complication and reintervention rates for the EVAR and OSR groups did not differ statistically (26.3% vs 16.9%, p = 0.122; 10.5% vs 11.5%, p = 0.981, respectively). Multivariate analysis revealed that greater aneurysm diameter (p = 0.012), EVAR procedure (p = 0.016), male gender (p = 0.023), and cerebrovascular diseases (p = 0.028) were independently positively associated with 5-year mortality. CONCLUSIONS Thirty-day mortality, and complication and reintervention rates for EVAR and OSR after elective AAA repair were similar. Although the EVAR procedure is an independent risk factor for 5-year mortality, higher age and greater proportion of comorbidities among EVAR patients may influence not only the choice of treatment modality, but also prognosis.
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Affiliation(s)
- Jüri Lieberg
- Department of Vascular Surgery, Tartu University Hospital, Tartu, Estonia Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | | | - Mart Kals
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia Institute for Molecular Medicine Finland, FIMM, HiLIFE, University of Helsinki, Helsinki, Finland
| | - Kaido Paapstel
- Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Jaak Kals
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, 8 Puusepa Street, Tartu 51014, Estonia Department of Vascular Surgery, Tartu University Hospital, Tartu, Estonia
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15
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Geraedts ACM, Mulay S, van Dieren S, Koelemay MJW, Balm R. Analysis of Outcomes After Endovascular Abdominal Aortic Aneurysm Repair in Patients With Abnormal Findings on the First Postoperative Computed Tomography Angiography. J Endovasc Ther 2021; 28:878-887. [PMID: 34315298 PMCID: PMC8573614 DOI: 10.1177/15266028211030539] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Purpose: Lifelong follow-up after endovascular abdominal aortic aneurysm repair (EVAR) is recommended due to a continued risk of complications, especially if the first postoperative imaging shows abnormal findings. We studied the long-term outcomes in patients with abnormalities on the first postoperative computed tomography angiography (CTA) following EVAR. Materials and Methods: This is a retrospective study of all consecutive patients who underwent elective EVAR for nonruptured abdominal aortic aneurysm (AAA) between January 2007 and January 2012 in 16 Dutch hospitals with follow-up until December 2018. Patients were included if the first postoperative CTA showed one of the following abnormal findings: endoleak type I–IV, endograft kinking, infection, or limb occlusion. AAA diameter, complications, and secondary interventions during follow-up were registered. Primary endpoint was overall survival, and other endpoints were secondary interventions and intervention-free survival. Kaplan-Meier analyses were used to estimate overall and intervention-free survival. Cox regression analyses were used to identify the association of independent determinants with survival and secondary interventions. Results: A total of 502 patients had abnormal findings on the first postoperative CTA after EVAR and had a median follow-up (interquartile range IQR) of 83.0 months (59.0). The estimated overall survival rate at 1, 5, and 10 years was 84.7%, 51.0%, and 30.8%, respectively. Age [hazard ratio (HR) 1.06, 95% confidence interval (CI) 1.05 to 1.10] and American Society of Anesthesiologists (ASA) classification (ASA IV HR 3.20, 95% CI 1.99 to 5.15) were significantly associated with all-cause mortality. Overall, 167 of the 502 patients (33.3%) underwent 238 secondary interventions in total. Fifty-eight patients (12%) underwent an intervention based on a finding on the first postoperative CTA. Overall survival was 38.4% for patients with secondary interventions and 44.5% for patients without (log rank; p=0.166). The intervention-free survival rate at 1, 5, and 10 years was 82.9%, 61.3%, and 45.6%, respectively. Conclusions: Patients with abnormalities on the first postoperative CTA after elective EVAR for infrarenal AAA cannot be discharged from regular imaging follow-up due to a high risk of secondary interventions. Patients who had a secondary intervention had similar overall survival as those without secondary interventions.
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Affiliation(s)
- Anna C M Geraedts
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Sana Mulay
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Susan van Dieren
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Mark J W Koelemay
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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16
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Abstract
Abdominal aortic aneurysm (AAA) is a common disease associated with significant cardiovascular morbidity and mortality. Up to now, there is still controversy on the choice of treatment method of AAA. Even so, the mechanisms of AAA progression are poorly defined, making targeting new therapies problematic. Current evidence favors an interaction of the hemodynamic microenvironment with local and systemic immune responses. In this review, we aim to provide an update of mechanisms in AAA progression, involving hemodynamics, perivascular adipose tissue, adventitial fibroblasts, vasa vasorum remodeling, intraluminal thrombus, and distribution of macrophage subtypes.
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Affiliation(s)
- Jiang-Ping Gao
- Department of Vascular Surgery, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China
| | - Wei Guo
- Department of Vascular Surgery, Chinese PLA General Hospital, Beijing, China
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17
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Väärämäki S, Uurto I, Suominen V. Postoperative imaging follow-up at 2 years as a predictor of long-term outcomes after endovascular aneurysm repair. J Vasc Surg 2021; 74:1853-1860. [PMID: 34174376 DOI: 10.1016/j.jvs.2021.05.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 05/17/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Lifelong imaging follow-up remains the reference standard after endovascular aneurysm repair (EVAR). Because the number of EVARs has been increasing, an individually optimized follow-up protocol is desirable. The aim of the present study was to investigate the possibility of creating such a protocol by evaluating patients' follow-up images and to compare the findings with their freedom from reintervention and abdominal aortic aneurysm (AAA) rupture. METHODS From 2000 to 2010, 282 patients with an AAA had undergone elective EVAR with the Zenith stent-graft. The patients were followed up annually until the end of 2019. The patients were categorized into two groups according to the presence of any endoleak or sac shrinkage at 2 years. Group A included those with no detectable endoleak plus aneurysm sac shrinkage of ≥5 mm (n = 137; 63%), and group B included those with any type of endoleak and/or no significant aneurysm sac shrinkage (<5 mm; n = 82; 37%). RESULTS The mean follow-up was 83 months (range, 0-229 months), and the overall survival at 2 years was 84% (n = 237). No significant difference was found in overall survival between groups A and B (P = .73). However, a significant difference was found in freedom from AAA rupture at 12 years, favoring group A (group A, 100%; group B, 91%; P = .002). Furthermore, in group A, the freedom from reintervention was 95% at 12 years compared with only 31% in group B (P < .001). The sensitivity of the categorization was 89% and the specificity was 74% for the finding of a complication requiring a reintervention during long-term follow-up. CONCLUSIONS Patients without an endoleak and a reduction of ≥5 mm in aneurysm size at 2 years had significantly fewer late reinterventions and ruptures during long-term follow-up compared with their counterparts using the Zenith stent-graft (Cook Medical, Bloomington, Ind). This finding suggests that, for these patients, the follow-up interval can be personalized and safely extended after 2 years.
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Affiliation(s)
- Suvi Väärämäki
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, and Tampere University, Faculty of Medicine and Life Sciences, Tampere, Finland.
| | - Ilkka Uurto
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, and Tampere University, Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Velipekka Suominen
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, and Tampere University, Faculty of Medicine and Life Sciences, Tampere, Finland
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Geraedts ACM, Mulay S, Vahl A, Wisselink W, Koelemay MJW, Balm R. Secondary Interventions and Long-term Follow-up after Endovascular Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2020; 71:381-391. [PMID: 32768546 DOI: 10.1016/j.avsg.2020.07.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Early morbidity and mortality are low after endovascular abdominal aneurysm repair (EVAR), but secondary interventions and late complications are common. The aim of the present multicenter cohort study is to detail the frequency and indication for interventions after EVAR and the impact on long-term survival. METHODS A retrospective multicenter cohort study of secondary interventions after elective EVAR for an infrarenal abdominal aortic aneurysm was conducted. Consecutive patients (n = 349) undergoing EVAR between January 2007 and January 2012 were analyzed, with long-term follow-up until December 2018. Those requiring intervention were classified in accordance with the indications and specific nature of the intervention and treatment. The primary study end point was overall survival classified for patients with and without intervention. Kaplan-Meier analysis was used to estimate overall survival for those who did and who did not undergo secondary interventions. Univariable and multivariable Cox regression were performed to identify independent variables associated with mortality. RESULTS Some 56 patients (16%) underwent 72 secondary interventions after EVAR during a median (interquartile range) follow-up period of 53.2 months (60.1). Some 45 patients (80.4%) underwent one intervention. Indications for intervention included mainly endograft kinking/outflow obstruction and type II endoleak. An endovascular technique was used in 40.3% of interventions. Median time to secondary intervention was 24.1 months. In 93 patients with abnormalities on imaging, no intervention was performed mainly because the abnormality had disappeared on follow-up imaging (43%). Kaplan-Meier curves showed no difference in survival for patients with and without secondary interventions (P = 0.153). Age (hazard ratio [HR]: 1.089, 95% confidence interval [CI]: 1.063-1.116), ASA classification (ASA III, IV HR: 1.517, 95% CI: 1.056-2.178) were significantly related to mortality. CONCLUSIONS Secondary intervention rates are still considerable after EVAR. Endograft kinking/outflow obstruction and endoleak type II are the most common indications for a secondary intervention. Secondary interventions did not adversely affect long-term overall survival after EVAR.
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Affiliation(s)
- Anna C M Geraedts
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Sana Mulay
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Anco Vahl
- OLVG, Department of Surgery, Amsterdam, The Netherlands
| | - Willem Wisselink
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Mark J W Koelemay
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
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Tigkiropoulos K, Stavridis K, Lazaridis I, Bontinis E, Zournatzi I, Kolaki N, Karamanos D, Saratzis N. Outcomes of Endovascular Aneurysm Repair Using the Anaconda Stent-Graft. J Endovasc Ther 2020; 27:462-467. [PMID: 32517558 DOI: 10.1177/1526602820918875] [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: 11/15/2022]
Abstract
Purpose: To report outcomes of elective endovascular aneurysm repair (EVAR) using the Anaconda stent-graft in a tertiary vascular center. Materials and Methods: A retrospective study was conducted of 271 patients (mean age 71.5 years; 260 men) who underwent elective EVAR for abdominal aortic aneurysm using the Anaconda stent-graft from January 2006 to January 2017. Median aneurysm diameter was 58 mm (range 50-90). All patients were anatomically suitable for EVAR according to the 2003 version of the instructions for use. Follow-up included computed tomography angiography at 1, 6, and 12 months and yearly thereafter for the first 4 years and then every 2 years. Primary outcomes included technical success and 30-day aneurysm-related mortality and complications; secondary outcomes were overall and aneurysm-related mortality and aneurysm-related morbidity in follow-up. Results: The Anaconda stent-graft was implanted successfully in all patients. Primary and secondary technical success rates were 99.6% and 100%, respectively. Three patients (1.1%) died within 30 days of causes unrelated to the aneurysm, while 15 patients (5.5%) suffered perioperative complications. Median follow-up was 72 months (range 14-141). The overall type I endoleak rate was 4.7% (11 proximal, 2 distal). Late aneurysm-related complications were observed in 48 patients (17.3%); aneurysm-related mortality was 1.4% (n=4). Non-aneurysm-related mortality was 21.0% (n=57). Freedom from reintervention was 95.2% at 1 year, 98% at 2 years, and 90% at 6 years. There was no significant difference in the overall limb graft occlusion rate between the second- and third-generation devices. Conclusion: Results in our cohort study demonstrate that the Anaconda stent-graft has satisfactory early and late results with low aneurysm-related mortality.
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Affiliation(s)
- Konstantinos Tigkiropoulos
- Vascular Unit, 1st University Surgical Department, Papageorgiou General Hospital, Aristotle University, Thessaloniki, Greece
| | - Kyriakos Stavridis
- Vascular Unit, 1st University Surgical Department, Papageorgiou General Hospital, Aristotle University, Thessaloniki, Greece
| | - Ioannis Lazaridis
- Vascular Unit, 1st University Surgical Department, Papageorgiou General Hospital, Aristotle University, Thessaloniki, Greece
| | - Evangelos Bontinis
- Vascular Unit, 1st University Surgical Department, Papageorgiou General Hospital, Aristotle University, Thessaloniki, Greece
| | - Ioulia Zournatzi
- Vascular Unit, 1st University Surgical Department, Papageorgiou General Hospital, Aristotle University, Thessaloniki, Greece
| | - Nikoletta Kolaki
- Vascular Unit, 1st University Surgical Department, Papageorgiou General Hospital, Aristotle University, Thessaloniki, Greece
| | - Dimitrios Karamanos
- Vascular Unit, 1st University Surgical Department, Papageorgiou General Hospital, Aristotle University, Thessaloniki, Greece
| | - Nikolaos Saratzis
- Vascular Unit, 1st University Surgical Department, Papageorgiou General Hospital, Aristotle University, Thessaloniki, Greece
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20
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Väärämäki S, Salenius J, Pimenoff G, Uurto I, Suominen V. Overall outcome after endovascular aneurysm repair with a first-generation stent graft (Vanguard): A 20-year single-center experience. J Vasc Surg 2020; 72:896-903. [PMID: 32139310 DOI: 10.1016/j.jvs.2019.11.027] [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: 07/18/2019] [Accepted: 11/03/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The problems with first-generation stent grafts for endovascular aneurysm repair are well known, but their long-term outcome remains to be established. The purpose of the study was to characterize the outcome of patients treated for abdominal aortic aneurysm (AAA) with a first-generation stent graft, Vanguard (Boston Scientific, Natick, Mass), in a single academic center with a follow-up of up to 20 years. METHODS There were 48 AAA patients electively treated with a Vanguard stent graft between February 1997 and November 1999. The patients were monitored annually until the end of 2018. The outcomes were overall survival and the number of graft-related complications and reinterventions. RESULTS The mean age was 70 years (range, 54-85 years), and the mean follow-up was 107 months (range, 6-262 months). All stent grafts were successfully implanted, but 90% of the patients encountered graft-related complications during follow-up. The most common complications were endoleaks (type I, 27%; type II, 29%; type III, 31%), stent fracture (46%), graft thrombosis (31%), and migration (40%). A total of 40 (83%) patients required a secondary procedure during long-term follow-up. The endovascular method for treating the complication was successful in 73 (87%) of 84 cases. There were no primary conversions, but 10 patients (21%) required a late conversion. In five cases, the complications required relining with a newer device. There were four AAA ruptures (8.3%), two of them fatal. The cumulative overall survival rates were 94%, 69%, 33%, 15%, and 13% at 1 year, 5 years, 10 years, 15 years, and 20 years, respectively. CONCLUSIONS The use of the Vanguard, a first-generation stent graft, was associated with multiple graft-related complications. However, these complications could mainly be treated by endovascular means. The Vanguard stent graft is a good example of how new technology can cause unpredictable problems that can magnify the workload and endanger the patient's well-being even decades after the initial procedure.
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Affiliation(s)
- Suvi Väärämäki
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland.
| | - Juha Salenius
- Division of Vascular Surgery, Department of Surgery, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Georg Pimenoff
- Division of Interventional Radiology, Department of Radiology, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Ilkka Uurto
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Velipekka Suominen
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland
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21
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Davies RSM. Endovascular Aneurysm Repair (EVAR) or Endovascular Aneurysm Control (EVAC)? Eur J Vasc Endovasc Surg 2019; 58:189. [PMID: 31005509 DOI: 10.1016/j.ejvs.2019.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 03/28/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Robert S M Davies
- Leicester Vascular Institute, University Hospitals of Leicester NHS Foundation Trust, Leicester, UK.
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