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Gedney R, Barksdale C, Wright AS, Genovese EA, Ruddy JM. Hostile neck anatomy contributes to higher rates of reintervention following endovascular aortic repair for ruptured infrarenal abdominal aortic aneurysm. Vascular 2024:17085381241239428. [PMID: 38478714 DOI: 10.1177/17085381241239428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Ruptured abdominal aortic aneurysms (AAA) presenting with hostile neck anatomy can represent a challenge in surgical decision-making. We hypothesized that, patients who require reinterventions have higher rates of compromised neck anatomy at initial presentation and may indicate a need for altered surveillance paradigm. METHODS Patients presenting with ruptured AAA to a single tertiary care institution from 2014 to 2021 were retrospectively reviewed. Those treated with infrarenal EVAR, with no prior aortic surgeries, and with available pre-operative computed tomography (CT) scans were included. Demographics, timing and type of reintervention, follow-up, and survival were collected. CT scans were assessed for hostile neck anatomy via measurements of diameter, length, angle, taper, bulge, calcification, and thrombus. Demographics, comorbidities, and neck anatomy of those with and without reintervention were compared using Fischer's Exact and Student's T-test. Survival was analyzed via Kaplan-Meier and log-rank test. RESULTS Eighty-nine patients were available for analysis, 37 of which met inclusion criteria. Intraoperative death occurred in 3 patients (8.1%) and 1 patient (2.7%) was intraoperatively converted to an open repair. Thirty-day and 1-year survival were 97% and 91%, respectively. The reintervention rate was 30% (n = 10), occurring at a median of 200 days (18-2053 days) after the index operation. All patients requiring reintervention met hostile neck criteria (p = .002) and had a statistically higher number of hostile neck criteria (1.80 vs 0.87, p = .03). Thirty percent (n = 3) of patients that received a reintervention had neck diameter greater than 3 cm, compared to zero patients in the non-reintervention group (p = .022). Proximal reinterventions (n = 5) had statistically higher neck diameters and neck angle compared to the non-reintervention group. CONCLUSION Infrarenal rEVAR is effective at preventing acute mortality despite specific anatomic considerations that may contribute to the higher reintervention rates, and therefore those parameters ought to be considered when following patients in the post-intervention period.
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Affiliation(s)
- Ryan Gedney
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Christian Barksdale
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Antwana Sharee Wright
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Elizabeth A Genovese
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Jean Marie Ruddy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
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Houser A, Martinez C, Tassiopoulos A. The Challenge of Treating Abdominal Aortic Aneurysms with Hostile Neck Anatomy: An Overview. J Clin Med 2024; 13:1460. [PMID: 38592279 PMCID: PMC10932176 DOI: 10.3390/jcm13051460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/16/2024] [Accepted: 02/17/2024] [Indexed: 04/10/2024] Open
Abstract
Hostile aortic neck anatomy challenges the outcomes of endovascular abdominal aortic aneurysm repair (EVAR). Besides reverting to open surgical repair (OSR), thoughtful endograft selection and a number of advanced endovascular techniques have been suggested as potential solutions for preventing proximal seal zone complications, improving EVAR durability, and preventing aneurysm-related death. Each technique is associated with advantages and limitations and there has not been a credible direct comparison amongst them in the form of a well-designed prospective trial. The not infrequent presence of multiple hostile anatomic characteristics further complicates decision making and challenges the surgeon's skills. This paper serves as an overview of hostile neck anatomy and its implications on EVAR. We provide a concise literature review with the purpose of outlining the treatment modalities and outcomes in this patient population.
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Affiliation(s)
- Alex Houser
- Division of Vascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (A.H.); (C.M.)
| | - Camilo Martinez
- Division of Vascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (A.H.); (C.M.)
| | - Apostolos Tassiopoulos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Stony Brook Medicine Health Sciences Center, T-19, Room 020, Stony Brook, NY 11794, USA
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Lee J, Oh PC, Jang AY, Ahn CM, Choi D, Ko YG, Kang WC. Long-Term Outcomes of Endovascular Repair Within and Outside the Instructions for Use in Korean Patients With Abdominal Aortic Aneurysm. J Endovasc Ther 2024:15266028241232915. [PMID: 38414229 DOI: 10.1177/15266028241232915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
OBJECTIVE Endovascular aneurysm repair (EVAR) has been used worldwide to treat abdominal aortic aneurysms (AAAs). Outcomes after EVAR within and outside the instruction for use (IFU) remain controversial. We analyzed long-term outcomes of EVAR within-the-IFU compared with that outside-the-IFU and baseline clinical/anatomical characteristics that influence outcomes of EVAR. METHODS The study included 546 patients who underwent EVAR for infrarenal AAA from 1997 to 2021 at 2 Korean medical centers. The primary endpoint was graft-related adverse events (GRAEs), including type 1 or 3 endoleak, reintervention (included open conversion), aneurysm sac enlargement, aneurysm-related mortality (ARM), rupture, stent-graft migration, and stent thrombotic occlusion. RESULTS The patients who underwent EVAR outside the IFU were 287 (52.6%). A neck angle of >60° was most common outside the IFU criteria (n=146, 50.9%). This study revealed that patients outside the IFU had a higher rate of GRAEs compared with patients within the IFU (hazard ratio [HR]: 1.879; 95% confidence interval [CI]: 1.045-2.386). A neck angle of >60° was a significant risk factor for GRAEs (adjusted HR: 2.229; 95% CI: 1.418-3.503), type 1 or 3 endoleak (adjusted HR: 2.640; 95% CI: 1.343-5.189), and reintervention (adjusted HR: 1.891; 95% CI: 1.055-3.388). CONCLUSIONS Our study revealed EVAR with outside the IFU was associated with increased GRAEs, mainly attributed to endoleak and ARM, compared with EVAR with within the IFU. In addition, severe neck angulation was an independent risk factor for GRAEs, type 1 or 3 endoleak, and reintervention. CLINICAL IMPACT Our study revealed endovascular aneurysm repair (EVAR) with outside-the-instruction for use (IFU) was associated with increased graft-related adverse events (GRAEs) compared with EVAR with within-the-IFU. In the low-risk population, the incidence of GRAEs and Aneurysm related mortality were higher in the outside-the-IFU group rather than within-the-IFU group. In addition, severe neck angulation was an independent risk factor for GRAEs, type 1 or 3 endoleak and reintervention.
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Affiliation(s)
- Joonpyo Lee
- Department of Cardiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Pyung Chun Oh
- Department of Cardiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Albert Youngwoo Jang
- Department of Cardiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woong Chol Kang
- Department of Cardiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
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Jan Boer G, Bekken JA, Kuijper TM, Vroegindeweij D, Fioole B. The Ratio Between the Infrarenal and Suprarenal Aortic Diameter Is a Predictor of Durable Proximal Seal After Endovascular Aneurysm Repair. J Endovasc Ther 2024:15266028241228803. [PMID: 38323563 DOI: 10.1177/15266028241228803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
OBJECTIVES The aim of this study was to assess whether the ratio of the mean infrarenal neck diameter to the suprarenal aortic diameter is a predictor for a durable proximal seal after endovascular aneurysm repair (EVAR). METHODS A total of 439 patients who underwent elective EVAR between 2004 and 2018 in a single vascular referral center met our inclusion criteria. Ratios were calculated by dividing the mean infrarenal neck diameter by 4 different suprarenal aortic diameters. Patients who developed a late type 1A endoleak (n=20) or proximal neck dilatation mandating revision (n=8) were compared with the 411 patients without long-term proximal seal complications. RESULTS Patients who developed a late type 1A endoleak had more frequently hypertension, a shorter infrarenal neck length, and a larger mean infrarenal neck diameter. The ratio of the mean infrarenal neck diameter to all 4 suprarenal aortic diameters was higher in the late type 1A endoleak group compared with the group without a late type 1A endoleak. Least absolute shrinkage and selection operator (LASSO) logistic regression identified a combination of 6 variables as the best combination to predict a late type 1A endoleak: presence of hypertension, increased mean infrarenal neck diameter, decreased aneurysm neck length, larger ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the superior mesenteric artery (SMA), larger ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the upper renal artery, and increased β-angle. Of these, based on both the univariate area under the curve (AUC) and optimal LASSO model restricted to a single predictor, the ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the SMA (AUC, 0.770; cutoff value, 0.997) was considered the best prognostic variable. CONCLUSION The ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the SMA is a good predictor for a late type 1A endoleak. Patients with mean infrarenal neck diameter larger than the diameter proximal to the SMA (ratio >1) are at risk for a late type 1A endoleak. CLINICAL IMPACT In this single-center, retrospective cohort study, we found that the ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the SMA is a good predictor for a late type 1A endoleak. We conclude that the suprarenal diameter must be taken into account before assessing endovascular aortic aneurysm repair eligibility. Patients with a ratio >1 may not be the best candidates for a durable result after EVAR and may be better off with fenestrated EVAR or open repair.
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Affiliation(s)
- Gert Jan Boer
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Joost A Bekken
- Department of Vascular Surgery, NoordWest Hospitalgroup, Haarlem, The Netherlands
| | | | | | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, The Netherlands
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Ke ZX, Chen GZ, Hu K, Zhang S, Zhou P, Chen DX, Li YQ, Li Q, Yang C. Safety and Efficacy of Endovascular Aortic Repair for Abdominal Aortic Aneurysms with a Hostile Neck Anatomy. Curr Med Sci 2023; 43:1221-1228. [PMID: 38153630 DOI: 10.1007/s11596-023-2822-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 01/14/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE This study aimed to investigate the safety and efficacy of endovascular aortic repair (EVAR) for the treatment of an abdominal aortic aneurysm (AAA) with a hostile neck anatomy (HNA). METHODS From January 1, 2015 to December 31, 2019, a total of 259 patients diagnosed with an AAA who underwent EVAR were recruited into this study. Based on the morphological characteristics of the proximal neck anatomy, the patients were divided into the HNA group and the friendly neck anatomy (FNA) group. The patients were followed up for up to 4 years. RESULTS The average follow-up time was 1056.1±535.5 days. Type I endoleak occurred in 4 patients in the HNA group, and 2 patients in the FNA group. Neither death nor intraoperative switch to open repair occurred in either group. The time of the operation was significantly longer in the HNA group (FNA vs. HNA, 99.2±51.1 min vs. 117.5±63.8 min, P=0.011). There were no significant differences in short-term clinical success rate (P=0.228) or midterm clinical success rate (P=0.889) between the two groups. The overall mortality rate was 10.4%, and Kaplan-Meier survival analysis indicated that the two groups had similar cumulative survival rates at the end of the follow-up period (P=0.889). CONCLUSION EVAR was feasible and safe in patients with an AAA with a proximal HNA. The early and midterm results were promising; however, further studies are needed to verify the long-term effectiveness of EVAR.
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Affiliation(s)
- Zun-Xiang Ke
- Department of Emergency Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ge-Zheng Chen
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ke Hu
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shan Zhang
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Peng Zhou
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Dian-Xi Chen
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yi-Qing Li
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Qin Li
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Chao Yang
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Arko FR, Pearce BJ, Henretta JP, Fugate MW, Torsello G, Panneton JM, Peng Y, Edward Garrett H. Five-year outcomes of endosuture aneurysm repair in patients with short neck abdominal aortic aneurysm from the ANCHOR registry. J Vasc Surg 2023; 78:1418-1425.e1. [PMID: 37558144 DOI: 10.1016/j.jvs.2023.07.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/24/2023] [Accepted: 07/29/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVE Hostile aortic neck anatomies such as proximal short necks are known to put patients at an increased risk for type IA endoleaks, migration, and need for reinterventions. The Heli-FX EndoAnchor System was designed to improve seal of aortic stent grafts. Endosuture aneurysm repair (ESAR) using EndoAnchors with the Endurant stent graft has been shown to be safe and effective for the treatment of patients with short necks through one year. This study reports the 5-year patient outcomes of the Aneurysm Treatment using the Heli-FX EndoAnchor System Global Registry (ANCHOR) short neck regulatory cohort. METHODS The 70 patients from the ANCHOR Registry were cohort submitted to regulators for approval of the Endurant short neck indication. Patients had an infrarenal neck length of ≥ 4 mm and <10 mm. At 5 years, this short neck cohort had clinical and imaging follow-up compliance rates of 85% (28/33) and 70% (23/33), respectively. RESULTS The short neck cohort had a mean age of 71.3±8.1 years and was 27.1% (19/70) female. Kaplan Meier freedom from all-cause mortality was 68.5 ± 6.2%, freedom from aneurysm-related mortality was 90.1 ± 4.5%, freedom from any endovascular or surgical secondary procedure was 76.9 ± 7.2%, and freedom from rupture was 95.6 ± 3.2%. Eight patients had a total of nine type IA endoleaks detected through 5 years, of which three resolved spontaneously by the next follow-up visit. There were two patients with renal complications who did not undergo reintervention and there were no device migrations reported through 5 years. After 5 years, 68.2% of patients (15/22) had sac regression, 13.6% (3/22) had stable sacs, and 18.2% (4/22) had increased sac diameter as compared with their 1-month measurements. CONCLUSIONS After ESAR treatment using Heli-FX EndoAnchors with Endurant, the 5-year outcomes of the short neck cohort from the ANCHOR registry had encouraging results with regards to proximal neck-related complications, secondary procedures, and sac regression. This review of ESAR in patients with short proximal necks showed positive outcomes through 5 years although follow-up of a larger cohort is necessary.
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Affiliation(s)
- Frank R Arko
- Division of Vascular and Endovascular Surgery, Carolinas Medical Center, Charlotte, NC.
| | - Benjamin J Pearce
- Division of Vascular and Endovascular Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - John P Henretta
- Division of Vascular and Endovascular Surgery, Mission Hospital, Asheville, NC
| | - Mark W Fugate
- Division of Vascular and Endovascular Surgery, Chattanooga Heart Institute Memorial Hospital, Chattanooga, TN
| | - Giovanni Torsello
- Division of Vascular and Endovascular Surgery, St. Franziskus-Hospital, Münster, Germany
| | - Jean M Panneton
- Division of Vascular and Endovascular Surgery, Eastern Virginia Medical School, Norfolk, VA
| | - Yun Peng
- Division of Vascular and Endovascular Surgery, Medtronic Inc., Santa Rosa, CA
| | - H Edward Garrett
- Division of Vascular and Endovascular Surgery, University of Tennessee, Memphis, TN
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Chinsakchai K, Sirivech T, Moll FL, Tongsai S, Hongku K. The Correlation of Aortic Neck Angle and Length in Abdominal Aortic Aneurysm with Severe Neck Angulation for Prediction of Intraoperative Neck Complications and Postoperative Outcomes after Endovascular Aneurysm Repair. J Clin Med 2023; 12:5797. [PMID: 37762737 PMCID: PMC10531816 DOI: 10.3390/jcm12185797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/02/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVES Endovascular aneurysm repair (EVAR) in a hostile neck has been associated with adverse outcomes. We aimed to determine the association of infrarenal aortic neck angle and length and establish an optimal cutoff value to predict intraoperative neck complications and postoperative outcomes. METHODS This was a retrospective review of patients with an intact infrarenal abdominal aortic aneurysm (AAA) with severe neck angulation (>60 degrees) who underwent EVAR from October 2010 to October 2018. Demographic data, aneurysm morphology, and operative details were collected. The ratio of neck angle and length was calculated as the optimal cutoff value of the aortic neck angle-length index. The patients were categorized into two distinct groups using latent profile analysis, a statistical technique employed to identify concealed subgroups within a larger population by examining a predetermined set of variables. Intraoperative neck complications, adjunct neck procedures, and early and late outcomes were compared. RESULTS 115 patients were included. Group 1 (G1) had 95 patients with an aortic neck angle-length index ≤ 4.8, and Group 2 (G2) had 20 patients with an aortic neck angle-length index > 4.8. Demographic data and aneurysm morphology were not significantly different between groups except for neck length (p < 0.001). G2 had more intraoperative neck complications than G1 (21.1% vs. 55%, p = 0.005). Adjunctive neck procedures were more common in G2 (18.9% vs. 60%, p < 0.001). The thirty-day mortality rate was not statistically different. G1 patients had a 5-year proximal neck re-intervention-free rate comparable to G2 patients (93.7% G1 vs. 87.5% G2, p = 0.785). The 5-year overall survival rate was not statistically different (59.9% G1 vs. 69.2% G2, p = 0.891). CONCLUSIONS Patients with an aortic neck angle-length index > 4.8 are at greater risk of intraoperative neck complications and adjunctive neck procedures than patients with an aortic neck angle-length index ≤ 4.8. The 5-year proximal neck re-intervention-free rate and the 5-year survival rate were not statistically different. Based on our findings, this study suggests that the aortic neck angle-length index is a reliable predictor of intraoperative neck complications during EVAR in AAA with severe neck angulation.
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Affiliation(s)
- Khamin Chinsakchai
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (T.S.); (K.H.)
| | - Thana Sirivech
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (T.S.); (K.H.)
| | - Frans L. Moll
- Vascular Surgery Department, University Medical Center Utrecht, 3584 Utrecht, The Netherlands;
| | - Sasima Tongsai
- Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand;
| | - Kiattisak Hongku
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (T.S.); (K.H.)
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Georgiadis GS, Schoretsanitis N, Argyriou C, Nikolopoulos E, Kapoulas K, Georgakarakos EI, Ktenidis K, Lazarides MK. Long-term outcomes of the Endurant endograft in patients undergoing endovascular abdominal aortic aneurysm repair. J Vasc Surg 2023; 78:668-678.e14. [PMID: 37141949 DOI: 10.1016/j.jvs.2023.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE/BACKGROUND To investigate the long-term outcomes after endovascular aneurysm repair (EVAR) in a real-world setting using the Endurant endograft (EG). METHODS 184 EVAR candidates treated with the Endurant family EGs in a single vascular center were prospectively enrolled from January 2009 to December 2016. Kaplan-Meir estimates of long-term standardized primary and secondary outcome measures were performed. Per protocol, subgroup comparison analysis was performed in three groups: patients treated within instructions for use (in-IFU) vs patients treated outside IFU (outside-IFU), EVAR in patients receiving the Endurant proximal diameter 32 or 36 mm EG vs those receiving the <32 mm diameter EG and EVAR with various Endurant EG versions. RESULTS The mean follow-up was 75.09 ± 37.9 months (range: 4.1-172 months). The median age of the patients was 72.96 ± 7.03 years (range: 55-88 years). A total of 177 patients were male (96.2%). Compliance with IFU was followed in 107 patients (58.2%). Overall survival was 69.5% and 48% at 5 and 8 years, respectively. Of the 102 all-cause deaths, 7 (6.9%) were aneurysm related. Six of these postimplant deaths occurred in patients presented with aneurysm rupture from type Ia or/and type Ib endoleak. At 5, 8, and 10 years of observation, freedom from aneurysm rupture, open surgical conversion, type I/III endoleak, any type of endoleak, aneurysm-related secondary intervention probabilities, and neck-related events were as follows: 98.1%, 95%, and 89.4%; 95.1%, 91.2%, and 85.7%; 93.6%, 87.3%, and 83.9%; 83.4%, 74%, and 70.9%; 89.8%, 76.7%, and 72%; and 96.3%, 90%, and 87.6%, respectively. Corresponding clinical success was 90%, 77.4%, and 68.4%, respectively. Patients treated outside-IFU had significantly higher risk of aneurysm rupture, open surgical conversion probability, occurrence of type I/III endoleak, and chance of reinterventions and lower clinical success probabilities compared with the in-IFU counterparts at 5 and 8 years. This statistical difference remained when type Ia endoleak or endoleak of any type was considered independently. In addition, it was stronger in patients having extreme anatomic boundaries (>1 hostile anatomic condition), when aneurysm-related death, aneurysm rupture, and clinical success at 5 years were considered. Overall proximal migration and limb occlusion were recorded in 1.1% and 4.9% of the patients, respectively. Overall reintervention rate was 17.4%. An increase in aneurysm sac diameter was observed in 12.5% of patients and was not related to IFU status. The Endurant version or the proximal EG diameter had no significant association with the chance of any complication or adverse event. CONCLUSIONS The data confirmed the durability of the Endurant EG, achieving promising long-term outcomes in a real-world setting. However, its positive performance must be interpreted with caution in patients treated off-label especially those with extreme anatomic boundaries. In this cohort, some of EVAR advantages might be lost in the late future. Further similar studies are warranted.
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Affiliation(s)
- George S Georgiadis
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Thrace, Greece.
| | | | - Christos Argyriou
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Thrace, Greece
| | | | | | - Efstratios I Georgakarakos
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Thrace, Greece
| | - Kyriakos Ktenidis
- Department of Vascular Surgery, AHEPA General Hospital of Thessaloniki, Thessaloniki Greece
| | - Miltos K Lazarides
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Thrace, Greece
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Varkevisser RRB, Patel PB, Swerdlow NJ, Li C, Rastogi V, Verhagen HJM, Lyden SP, Schermerhorn ML. The Impact of Proximal Neck Anatomy on the 5-Year Outcomes Following Endovascular Aortic Aneurysm Repair With the Ovation Stent Graft. J Endovasc Ther 2023:15266028231195771. [PMID: 37646116 DOI: 10.1177/15266028231195771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
PURPOSE Hostile proximal neck anatomy has historically been associated with worse outcomes for endovascular aortic aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA). We investigated the impact of proximal neck anatomy on the outcomes following EVAR with the Ovation abdominal stent graft (Endologix, Irving, Calif). METHODS We used prospectively collected data from the Effectiveness of Custom Seal with Ovation: Review of the Evidence database, compromised of pooled data from 6 clinical trials and the European Post-Market Registry of patients undergoing elective infrarenal EVAR (2009-2017). We investigated the impact of short neck length (<10 mm), wide neck diameter (≥28 mm), reverse taper shape (>10%), and neck angulation (>45°) on the outcomes. The primary outcome was type IA endoleak. Secondary outcomes included any type I/III endoleak, sac expansion, aneurysm-related reinterventions, and all-cause and aneurysm-related mortality, and a combined endpoint of type IA endoleak, graft migration, AAA-related reintervention, conversion, and aneurysm rupture. We used Kaplan-Meier analysis and Cox proportional hazards models to estimate the 30 day and 5 year rates and assess univariate and risk-adjusted differences. RESULTS Of the 1020 patients, 60 patients had a short neck, 113 had a wide neck diameter, 279 were reverse taper shaped, and 99 had neck angulation >45°. Wide proximal neck was associated with higher 5 year type IA endoleak estimates compared with favorable neck anatomy (7.1% vs 4.3%; p=0.02). No association with 5 year type IA endoleak was found for short neck length (1.7% vs 4.3%; p=0.52), reverse taper shape (3.2% vs 4.3%; p=0.99), or neck angulation (6.1% vs 4.3%; p=0.13). A wide neck diameter compared with favorable anatomy was also associated with higher 5 year estimates of graft migration (3.8% vs 0.4%; p=0.03) and the combined neck-related adverse outcome endpoint (16% vs 9.5%; p=0.002). The estimates of aneurysm sac expansion, rupture, and overall and aneurysm-related mortality were similar between the hostile proximal neck anatomy cohorts and favorable anatomy. CONCLUSION Wide proximal neck is associated with higher 5 year type IA endoleak rates for patients treated with the Ovation stent graft. However, short neck length, reverse taper shape, and neck angulation are not associated with higher 5 year type IA endoleak rates. CLINICAL IMPACT Hostile proximal neck anatomy has historically been associated with worse outcomes for endovascular aortic aneurysm repair of abdominal aortic aneurysms. The Ovation stent graft platform uses a different proximal sealing method using a polymer inflatable ring, aiming to improve sealing between the graft and aortic wall. This study demonstrated that short, angulated, and reverse taper-shaped neck anatomy did not result in increased type IA endoleak estimates in patients treated with the Ovation stent graft platform. Potentially, the different sealing mechanisms played a role in mitigating the historically worse outcomes in patients with short, angulated, and reverse taper-shaped neck anatomy.
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Affiliation(s)
- Rens R B Varkevisser
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Chun Li
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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10
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De Freitas S, D'Ambrosio N, Fatima J. Infrarenal Abdominal Aortic Aneurysm. Surg Clin North Am 2023; 103:595-614. [PMID: 37455027 DOI: 10.1016/j.suc.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Abdominal aortic aneurysms are found in up to 6% of men and 1.7% of women over the age of 65 years and are usually asymptomatic. The natural history of aortic aneurysms is continued dilation leading to rupture, which is associated with an overall 80% mortality. Of the patients with ruptured aneurysms that undergo intervention, half will not survive their hospitalization. Reduction in aneurysm mortality is therefore achieved by prophylactic repair during the asymptomatic period. On a population-based level, this is supported by abdominal aortic aneurysm screening programs. Approximately 60% of abdominal aortic aneurysms are confined to the infrarenal portion of the aorta and are amenable to repair with off-the-shelf endovascular devices. Endovascular techniques have now replaced open surgery as the primary modality for aneurysm repair.
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Affiliation(s)
- Simon De Freitas
- Department of Vascular Surgery, Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Nicole D'Ambrosio
- Department of Vascular Surgery, Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Javairiah Fatima
- Department of Vascular Surgery, Georgetown University Hospital, MedStar Health, Washington, DC, USA.
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11
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Tenorio ER, Vacirca A, Mesnard T, Sulzer T, Baghbani-Oskouei A, Mirza AK, Huang Y, Oderich GS. Technical tips and clinical experience with the Cook Triple inner arch branch stent-graft. J Cardiovasc Surg (Torino) 2023; 64:9-17. [PMID: 36598743 DOI: 10.23736/s0021-9509.22.12569-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Open surgical repair remains the gold standard for treatment for aortic arch diseases, but these operations can be associated with wide heterogeneity in outcomes and significant morbidity and mortality, particularly in elderly patients with severe comorbidities or those who had prior arch procedures via median sternotomy. Endovascular repair has been introduced as a less invasive alternative to reduce morbidity and mortality associated with open surgical repair. The technique evolved with new device designs using up to three inner branches for incorporation of the supra-aortic trunks. This manuscript summarizes technical tips and clinical experience with the triple inner arch branch stent graft for total endovascular repair of aortic arch pathologies.
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Affiliation(s)
- Emanuel R Tenorio
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Andrea Vacirca
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Thomas Mesnard
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Titia Sulzer
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Aleem K Mirza
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Ying Huang
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA -
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12
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Bordet M, Oliny A, Miasumu T, Tresson P, Lermusiaux P, Della Schiava N, Millon A. EndoSuture aneurysm repair versus fenestrated aneurysm repair in patients with short neck abdominal aortic aneurysm. J Vasc Surg 2023; 77:28-36.e3. [PMID: 36070845 DOI: 10.1016/j.jvs.2022.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/10/2022] [Accepted: 08/17/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to compare midterm results of EndoAnchors in EndoSuture aneurysm repair (ESAR) versus fenestrated endovascular aneurysm repair (FEVAR) in short neck abdominal aortic aneurysm (AAA). METHODS All patients who underwent an ESAR procedure for a short neck AAA at our center between September 2017 and May 2020 were considered for analysis. To form the control group, preoperative computed tomography angiography of patients who underwent FEVAR for juxtarenal AAA between April 2012 and May 2020 were reviewed and patients who met short neck criteria selected. A propensity-matched score on neck length and neck diameter was calculated, resulting in 18 matched pairs. AAA shrinkage, type Ia endoleaks (EL), AAA-related reinterventions, and AAA-related deaths were compared. RESULTS The median AAA diameter was 54 mm (interquartile range [IQR], 52-61 mm) versus 58 mm (IQR, 53-63 mm) with a median neck length of 8 mm (IQR, 6-12 mm) vs 10 mm (IQR, 6-13 mm) in ESAR and FEVAR patients, respectively. Technical success was 100% in both groups. Procedural success was 94% in the ESAR group versus 100% in the FEVAR group. The median procedure duration was 138 mm (IQR, 113-182 mm) vs 240 mm (IQR, 199-293 mm) ( P < .001) and the median length of stay was 2 days (IQR, 2-3 days) vs 7 days (IQR, 6-7 days) (P < .001) in ESAR and FEVAR patients, respectively. No major hospital complications were observed in ESAR patients compared with two in FEVAR patients (11%) with one transient acute kidney injury and one transient paraplegia. The median follow-up was 23 months (IQR, 19-33 months) vs 36 months (IQR, 22-57 months) with 67% versus 61% AAA shrinkage in the ESAR and FEVAR groups, respectively (P = .73). No type Ia EL, proximal neck-related reinterventions, or AAA-related deaths were observed in either group. No AAA-related reintervention was observed in the ESAR group versus three reinterventions in the FEVAR group (P = .23). CONCLUSIONS ESAR seems to be a safe technique with no major postoperative complications or reinterventions observed during follow-up. It seems to offer similar midterm results as FEVAR in terms of type Ia EL, aneurysm shrinkage, and aneurysm-related mortality. ESAR seems to be a good off-the-shelf alternative to FEVAR in case of technical constraints.
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Affiliation(s)
- Marine Bordet
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France; Université Claude Bernard Lyon 1, F-69621, Villeurbanne, France.
| | - Alexandre Oliny
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Tiphaine Miasumu
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Philippe Tresson
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Patrick Lermusiaux
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France; Université Claude Bernard Lyon 1, F-69621, Villeurbanne, France
| | - Nellie Della Schiava
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France; Université Claude Bernard Lyon 1, F-69621, Villeurbanne, France
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Xiang Y, Liu Y, Zhao J, Huang B, Wu Z, Chen X. Use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers increases the risk of postoperative acute kidney injury after elective endovascular abdominal aortic aneurysm repair. Chin Med J (Engl) 2022; 135:2836-42. [PMID: 36728509 DOI: 10.1097/CM9.0000000000002352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Endovascular abdominal aortic aneurysm repair (EVAR) is the major treatment for abdominal aortic aneurysm (AAA); however, EVAR still carries a considerable risk of acute kidney injury (AKI). The present study aimed to investigate the risk factors for AKI after elective EVAR procedures. METHODS This was a retrospective observational study. Eligible patients who underwent EVAR from September 2011 to March 2019 in West China Hospital were included. The primary outcome was the occurrence of AKI within two days after EVAR, which was defined by the Kidney Disease Improving Global Outcomes Clinical Practice Guideline. Demographics, comorbidities, medications, laboratory tests, anatomical parameters of AAA, and relative operative details were collected as variables. Univariable and multivariable logistic regression analyses were applied to identify the risk factors among variables, and covariate interactions were further assessed. RESULTS A total of 679 eligible patients were included. The incidence of postoperative AKI was 8.2% (56/679) in the whole cohort, and it was associated with a lower 5-year survival rate (63.5% vs . 80.9%; χ 2 = 4.10; P = 0.043). The multivariable logistic regression showed that chronic kidney disease (OR, 5.06; 95% CI: 1.43-17.95; P = 0.012), angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) (OR, 2.60; 95% CI: 1.17-5.76; P = 0.019), and short neck (OR, 2.85; 95% CI: 1.08-7.52; P = 0.035) were independent risk factors for postoperative AKI. In the covariate interaction analysis, the effect of ACEIs/ARBs use on postoperative AKI was similar across all subgroups ( P > 0.05), thereby suggesting a robust effect of ACEIs/ARBs use in all patients undergoing elective endovascular abdominal aortic aneurysm repair. CONCLUSIONS Postoperative AKI was associated with lower survival rate, and the use of ACEIs/ARBs was the only adjustable independent risk factor. Clinicians should consider withdrawing ACEIs/ARBs in high-risk patients undergoing elective endovascular abdominal aortic aneurysm repair to prevent postoperative AKI.
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14
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Cherfan P, Abdul-Malak OM, Liang NL, Eslami MH, Singh MJ, Makaroun MS, Chaer RA. Endovascular repair of abdominal and thoracoabdominal aneurysms using chimneys and periscopes is associated with poor outcomes. J Vasc Surg 2022; 76:311-317. [PMID: 35276255 PMCID: PMC10804879 DOI: 10.1016/j.jvs.2022.02.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/27/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Chimneys and periscopes are often used to treat pararenal or thoracoabdominal aneurysms de novo or after failed open or endovascular repair. We sought to describe our institutional experience, given their limited success and questionable long-term outcomes. METHODS We retrospectively reviewed the electronic records for patients treated with chimneys/periscopes from 1997 through 2020. Baseline characteristics, procedural details, periprocedural complications, reinterventions, and midterm outcomes were collected. RESULTS Fifty-eight patients (86 vessels) were treated; the median follow-up was 32 months (range, 0.03-104 months). There were 36% (n = 21) juxta-renal, 2% (n = 1) para-visceral, and 21% (n = 12) thoracoabdominal aneurysms, and 41% (n = 24) had pararenal failure of prior endovascular aneurysm repair (n = 17) or open repair (n = 7). Stent configuration for the majority of the 86 vessels (n = 80; 93%) treated were chimney configuration (n = 6 periscopes; 7%). The most common stent graft utilized was Viabahn, and 8.1% (n = 7) were reinforced with a bare metal stent. Although the majority of the cases were elective, 36.2% (n = 21) of the cases were urgent/emergent. At the conclusion of the initial procedure, 16 of 58 patients had an endoleak (gutter, 50% [8/16]; type Ia, 25% [4/16]; and type II, 25% [4/16]). On follow-up, 14 of 58 patients developed one or more endoleaks, with the most common endoleaks being a gutter endoleak (35% [7/20]). Other endoleaks observed included 30% (6/20) type III, 15% (3/20) type Ia, 15% (3/20) type Ib, and 5% (1/20) type II. Eleven of 58 patients underwent interventions for one or more endoleak (gutter, 33% [5/15]; type Ib, 20% [3/15]; type II, 7% [1/15]; and type III, 40% [6/15]). Twelve of 58 patients returned to the operating room for one or more procedures during the index hospitalization (five laparotomies, three dialysis access, three acute limb ischemia, and four chimney/periscope interventions). Ten of 58 patients underwent angioplasty/stenting for chimney/periscope compression or occlusion during the follow-up period. Survival was 61.3% at 1 year by Kaplan-Meier analysis (75% for elective, 37% for urgent/emergent) (aneurysm-related death, 22%). Cox hazard modeling showed that aneurysm diameter (hazard ratio, 1.03; 95% confidence interval, 1.004-1.05; P = .02) and urgent/emergent interventions (hazard ratio, 3.6; 95% confidence interval, 1.33-9.74; P = .01) were predictors of mortality. CONCLUSIONS Endovascular repair of aortic aneurysms with chimneys/periscopes is associated with poor outcomes, including limited technical success and aneurysm exclusion, as well as high morbidity and mortality, with a high rate of reinterventions both in the immediate postoperative period and on follow-up. They should be used only when other surgical or endovascular options are not possible.
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Affiliation(s)
- Patrick Cherfan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Othman M Abdul-Malak
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Michael J Singh
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
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15
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Dachs TM, Hauck SR, Kern M, Klausenitz C, Funovics MA. Fenestrierte und verzweigte endovaskuläre Aortenprothesen. Radiologie 2022; 62:586-591. [PMID: 35726073 PMCID: PMC9242898 DOI: 10.1007/s00117-022-01019-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 11/28/2022]
Abstract
Hintergrund Komplexe abdominelle aortale Pathologien, welche die Abgänge der Viszeralarterien miterfassen und bei denen kein adäquater proximaler Hals gegeben ist, können heute mittels fortgeschrittener FEVAR/BEVAR-Technik („fenestrated/branched endovascular aneurysm repair“) mit ähnlicher Sicherheit und vergleichbaren Erfolgsraten behandelt werden wie infrarenale Pathologien mit konventionellem EVAR. Methodische Innovationen und Probleme Zur Versorgung der Viszeralarterien können Fenestrierungen (bei Abgang der Viszeralarterie aus der nichtdilatierten Aorta) oder Verzweigungen (bei Abgang aus der dilatierten Aorta) verwendet werden. Beide Arten von Öffnungen werden mit Verbindungsstentgrafts (VSG) zu den Viszeralarterien abgedichtet. Mehrere Hersteller bieten fenestrierte oder verzweigte Endoprothesen an, wobei diese nur in Einzelfällen CE-zertifiziert und überwiegend in Europa als individuelle Sonderanfertigungen patientenbezogen erhältlich sind. Dies setzt eine entsprechende Lieferzeit voraus, was die Behandlung akuter Patienten mit solchen Prothesen unmöglich macht. Es liegen allerdings zwei Produkte von vierfach verzweigten Endoprothesen vor, die einen größeren Bereich der anatomischen Gegebenheiten bei thorakoabdominellen Aneurysmen auch im Akutfall abdecken und behandelbar machen. Sämtliche FEVAR- und BEVAR-Hauptkörper benötigen VSG, die durchgehend von Fremdherstellern stammen und von denen gegenwärtig noch kein einziges Produkt für diese Anwendung zertifiziert ist. Empfehlungen Da Probleme an Verbindungsstentgrafts eine wesentliche Ursache für Reinterventionen sind, sollte in der Nachsorge Knickbildungen und Brüchen an diesen Verbindungsstents besonderes Augenmerk geschenkt und von der Verwendung einschichtiger Designs beim BEVAR abgesehen werden.
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Affiliation(s)
- Theresa-Marie Dachs
- Abteilung für Kardiovaskuläre und Interventionelle Radiologie, Universitätsklinik für Radiologie und Nuklearmedizin, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Sven Rudolf Hauck
- Abteilung für Kardiovaskuläre und Interventionelle Radiologie, Universitätsklinik für Radiologie und Nuklearmedizin, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Maximilian Kern
- Institut für Radiologie, Klinik Floridsdorf, Wien, Österreich
| | - Catharina Klausenitz
- Abteilung für Kardiovaskuläre und Interventionelle Radiologie, Universitätsklinik für Radiologie und Nuklearmedizin, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Martin A Funovics
- Abteilung für Kardiovaskuläre und Interventionelle Radiologie, Universitätsklinik für Radiologie und Nuklearmedizin, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
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Trabold T, Richter GM, Rosner R, Geisbüsch P. [Endovascular aortic repair: the hostile aneurysm neck : Morphologic definition, impact on long-term outcome, and treatment options]. Radiologie (Heidelb) 2022; 62:563-569. [PMID: 35768584 DOI: 10.1007/s00117-022-01018-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Abstract
DEFINITION A hostile neck is defined by various anatomical conditions that describe a morphology of the proximal aneurysmal neck of infrarenal aortic aneurysms that is unfavorable for endovascular treatment (endovascular aortic repair, EVAR): proximal landing zone length ≤ 15 mm, angulation of the aortic neck > 60°, conical aortic neck, diameter of the aortic neck > 32 mm, and circumferential calcification/thrombus. EFFECTS ON OUTCOME These morphological parameters are not only associated with a higher perioperative technical failure rate (primary type 1 endoleak) but also with poorer long-term results (secondary type 1 endoleak) and thus a higher reintervention rate in standard EVAR, so that standard EVAR should be reserved for a few exceptions in these cases. TREATMENT OPTIONS Due to the rapid development of endovascular techniques in the last decade, we now have a variety of endovascular options for aneurysms with hostile necks, for both elective treatment and emergency care, in addition to conventional open surgery, which is still the standard method in many cases and is currently undergoing a renaissance: fenestrated endovascular aortic repair (FEVAR) as the method of first choice in the elective setting, EVAR with chimneys (ChEVAR), endosuture aneurysm repair (ESAR). An important option is the conservative approach, which can be a reasonable choice if the patient's preference is taken into account and a careful risk-benefit assessment is performed.
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Affiliation(s)
- Tobias Trabold
- Klinik für Diagnostische und Interventionelle Radiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70195, Stuttgart, Deutschland.
| | - Götz M Richter
- Klinik für Diagnostische und Interventionelle Radiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70195, Stuttgart, Deutschland
| | - Rebekka Rosner
- Klinik für Diagnostische und Interventionelle Radiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70195, Stuttgart, Deutschland
| | - Philipp Geisbüsch
- Klinik für Gefäßchirurgie, Endovaskuläre Chirurgie und Transplantationschirurgie, Klinikum Stuttgart, Stuttgart, Deutschland
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Rhee R, Oderich G, Han S, Long C, Muck P, Moore E, Matsumura J. One year results of the GORE® EXCLUDER® Conformable AAA Endoprosthesis (EXCC) system in the United States regulatory trial. J Vasc Surg 2022; 76:951-959.e2. [DOI: 10.1016/j.jvs.2022.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/05/2022] [Indexed: 11/26/2022]
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Soo Hoo AJ, Fitzgibbon JJ, Hussain MA, Scully RE, Servais AB, Nguyen LL, Gravereaux EC, Semel ME, Marcaccio EJ, Menard MT, Ozaki CK, Belkin M. Contemporary Indications for Open Abdominal Aortic Aneurysm Repair in the Endovascular Era. J Vasc Surg 2022; 76:923-931.e1. [PMID: 35367568 DOI: 10.1016/j.jvs.2022.03.866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND OBJECTIVES Despite the emergence of endovascular aneurysm repair (EVAR) as the most common approach to abdominal aortic aneurysm repair, open aneurysm repair (OAR) remains an important option. This study seeks to define the indications for OAR in the EVAR era and how these indications effect outcomes. METHODS A retrospective cohort study was performed of all OAR at a single institution from 2004 to 2019. Pre-operative computed tomography scans and operative records were assessed to determine the indication for OAR. These reasons were categorized into anatomical contraindications; systemic factors (connective tissue disorders, contraindication to contrast dye); and patient/surgeon preference (patients who were candidates for both EVAR and OAR). Perioperative and long-term outcomes were compared between the groups. RESULTS 370 patients were included in the analysis; 71.6% (265/370) had at least one anatomic contraindication to EVAR; 36% had two or more contraindications. The most common anatomic contraindications were short aortic neck length (51.6%), inadequate distal seal zone (19.2%), and inadequate access vessels (15.7%). The major perioperative complication rate was 18.1% and the 30-day mortality was 3.0%. No single anatomic factor was identified as a predictor of perioperative complications. Sixty-one patients (16.5%) had OAR based on patient/surgeon preference; these patients were younger; had lower incidences of coronary artery disease and chronic obstructive pulmonary disease; and they were less likely to require suprarenal cross clamping compared with patients who had anatomic and/or systemic contraindications to EVAR. The patient/surgeon preference group had a lower incidence of perioperative major complications (8.2% versus 20.1%, p=0.034), shorter length of stay (6 versus 8 days, p<0.001) and zero 30-day mortalities. The multivariable adjusted risk for 15-year mortality was lower for patient/surgeon preference patients (adjusted hazard ratio 0.44 [95% confidence interval 0.24-0.80], p=0.007) compared to those anatomic/systemic contraindications. CONCLUSIONS Within a population of patients who did not meet instruction for use (IFU) criteria for EVAR, no single anatomic contraindication was a marker for worse outcomes with OAR. Patients who were candidates for both aortic repair approaches but elected to have open surgical repair due to patient/surgeon preference have very low 30-day mortality and morbidity, and superior long-term survival rates compared with those patients who had OAR due to anatomic and/or systemic contraindications to EVAR.
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Affiliation(s)
- Andrew J Soo Hoo
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - James J Fitzgibbon
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Mohamad A Hussain
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA; Centre for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Rebecca E Scully
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Andrew B Servais
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Louis L Nguyen
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Edwin C Gravereaux
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Marcus E Semel
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Edward J Marcaccio
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
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Murzi M, Farneti PA, Rizza A, Di Sibio S, Palmieri C, Solinas M. Hybrid Approach in Acute and Chronic Aortic Disease. Medicina (B Aires) 2021; 58:49. [PMID: 35056357 PMCID: PMC8777634 DOI: 10.3390/medicina58010049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 11/26/2022] Open
Abstract
The management of patients with aortic disease that involves the ascending aorta, the aortic arch, and the descending aorta represent a surgical challenge. Open surgical repair remains the gold standard for aortic arch pathologies. However, this operation requires a cardiopulmonary bypass and a period of profound hypothermia and circulatory arrest, which carries a substantial rate of mortality and morbidity. For these reasons, hybrid arch repair that involves a combination of open surgery with endovascular aortic stent graft placement has been introduced as a therapeutic alternative for those patients deemed unfit for open surgical procedures. Hybrid repair requires varying degrees of invasiveness and can be performed as a single-stage procedure or as a two-stage procedure. The choice of the technique is multifactorial, depending on the characteristics of the diseased arch with regard to position of the stent graft proximal landing zone, patient fitness and comorbid status, as well as surgical expertise and hospital facilities. Among the evolving hybrid procedures is the so-called “frozen” or stented elephant trunk technique. Adapted from the classical elephant trunk technique, this approach facilitates the repair of a concomitant aortic arch and proximal descending aortic aneurysms in a single stage under circulatory arrest. This technique is increasingly being used to treat extensive thoracic aortic disease and has shown promising results.
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20
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Affiliation(s)
- Andres Schanzer
- From the Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester (A.S.); and the Division of Vascular and Endovascular Surgery, University of Texas Health Science Center, Houston (G.S.O.)
| | - Gustavo S Oderich
- From the Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester (A.S.); and the Division of Vascular and Endovascular Surgery, University of Texas Health Science Center, Houston (G.S.O.)
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21
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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: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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22
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Charitable JF, Li C, Maldonado TS. Use of Gore C-TAG with active control to treat a complex infrarenal abdominal aortic aneurysm. J Vasc Surg 2020; 73:2140-2143. [PMID: 33157188 DOI: 10.1016/j.jvs.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 10/16/2020] [Indexed: 11/18/2022]
Abstract
Complex abdominal aortic aneurysms (AAAs) can preclude the use of endovascular aortic repair. In patients unable to undergo open surgical repair (OSR), the use of endografts outside the instructions for use might be the only option. We present the case of a woman with a highly angulated infrarenal AAA neck who was unsuitable for OSR and was successfully treated using a Gore C-TAG conformable thoracic stent graft (W.L. Gore and Associates, Inc, Flagstaff, Ariz) with active control, Medtronic Heli-FX EndoAnchors (Medtronic Vascular, Minneapolis, Minn), and a bifurcated Gore Excluder endoprosthesis W.L. Gore and Associates). The repair was successful without evidence of an endoleak. Using a thoracic endograft outside of the instructions for use to treat infrarenal AAAs might be feasible for patients unable to undergo OSR.
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Affiliation(s)
- John F Charitable
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY
| | - Chong Li
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY
| | - Thomas S Maldonado
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY.
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Charitable JF, Li C, Maldonado TS. WITHDRAWN: The Use of Gore C-TAG with Active Control to Treat A Complex Infrarenal Abdominal Aortic Aneurysm. J Vasc Surg Cases Innov Tech 2020. [DOI: 10.1016/j.jvscit.2020.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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24
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Georgiadis GS, Chatzigakis PK, Kouvelos G, Argyriou C, Kopadis GC, Georgakarakos EI, Matsagkas M. Multicenter Mid-term Results After Endovascular Aortic Aneurysm Repair with the Incraft® Device. Ann Vasc Surg 2020; 72:464-478. [PMID: 32946999 DOI: 10.1016/j.avsg.2020.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/05/2020] [Accepted: 09/08/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Durability after endovascular aortic aneurysm repair (EVAR) is considered an ongoing topic of investigation and was always a point of concern with smaller profile devices. Recently released five-year clinical trial results using the Incraft® ultralow profile device are encouraging. However, additional real-life experience will need to assist these initial findings. Herein, we investigated the outcomes after EVAR, in real world practice using the Incraft® endograft (EG). MATERIAL AND METHODS Seventy-seven patients with infrarenal abdominal aortic aneurysms (AAA) ≥50 mm in diameter treated with the Incraft® device in three vascular centers were enrolled from November 2015 to July 2018. Follow-up was completed in August 2020. Selection of EVAR using the Incraft® device was individualized according to aorto-iliac morphologic features, comorbidities, history of previous abdominal surgery and preference of the patient. At the early phase of the study, we specifically opted for preferential use of this low profile EG mainly in cases of small and tortuous iliac vessels (more challenging access routes). At later stages, it was used according to surgeon preference and not specifically in complex anatomies (real-world conditions). End-points included technical success, perioperative complications, 30-day survival, endoleg patency, presence of endoleaks, sac enlargement >5 mm and clinical success. RESULTS The primary technical success rate was 97.4% before the addition of an aortic cuff and iliac extension for a type Ia and type Ib endoleak respectively, and the repair of a maldeployment iliac component (primary-assisted and secondary technical success, 100%). Intraoperative small type II endoleaks (visible in final angiogram) were noted in 19 patients (24.7%). There were no intraoperative deaths from AAA rupture, primary conversions or conversions to aortounilateral grafts. Two complications occurred, necessitating hybrid techniques for repair (replaced of a dislodged endoleg and distal external iliac artery hemostasis). No deaths were reported within 30 days. Occlusion of an endoleg, was observed in two patients, 6 and 14 months respectively after implantation (2.6%), and were treated by femoral-femoral PTFE bypass after unsuccessful endovascular recanalization. The latter required open conversion, 3 mo later, to repair compromised flow to the inflow iliac axis. Three patients (3.9%) experienced sac enlargement >5 mm in diameter compared with the 1-month CT scan. All of these had type II endoleaks and two received embolization procedures. Eleven patients died from causes unrelated to AAA repair. Clinical success was 97.3%, 92.8% and 89.4% through 1, 2 and 3 years respectively. CONCLUSIONS EVAR with the Incraft® device might be considered a reliable option in real-world conditions and not specifically only in complex iliac anatomies.
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Affiliation(s)
- George S Georgiadis
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece.
| | - Petros K Chatzigakis
- Department of Vascular Surgery, Gennimatas General Hospital of Athens, Athens, Greece
| | - George Kouvelos
- Department of Vascular Surgery, University of Thessaly, Larissa, Greece
| | - Christos Argyriou
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Georgios C Kopadis
- Department of Vascular Surgery, Gennimatas General Hospital of Athens, Athens, Greece
| | - Efstratios I Georgakarakos
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
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Schanzer A, Beck AW, Eagleton M, Farber MA, Oderich G, Schneider D, Sweet MP, Crawford A, Timaran C. Results of fenestrated and branched endovascular aortic aneurysm repair after failed infrarenal endovascular aortic aneurysm repair. J Vasc Surg 2020; 72:849-858. [DOI: 10.1016/j.jvs.2019.11.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/03/2019] [Indexed: 01/13/2023]
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26
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Kobayashi M, Hoshina K, Nemoto Y, Takagi S, Shojima M, Hayakawa M, Yamada S, Oshima M. A penalized spline fitting method to optimize geometric parameters of arterial centerlines extracted from medical images. Comput Med Imaging Graph 2020; 84:101746. [PMID: 32745635 DOI: 10.1016/j.compmedimag.2020.101746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 04/21/2020] [Accepted: 06/04/2020] [Indexed: 10/23/2022]
Abstract
In order to grasp the spatial and temporal evolution of vascular geometry, three-dimensional (3D) arterial bending structure and geometrical changes of arteries and stent grafts (SG) must be quantified using geometrical parameters such as curvature and torsion along the vasculature centerlines extracted from medical images. Here, we develop a robust method for constructing smooth centerlines based on a spline fitting method (SFM) such that the optimized geometric parameters of curvature and torsion can be obtained independently of digitization noise in the images. Conventional SFM consists of the 3rd degree spline basis function and 2nd derivative penalty term. In contrast, the present SFM uses the 5th degree spline basis function and 3rd and 4th derivative penalty terms, the coefficients of which are derived by the Akaike information criterion. The results show that the developed SFM can reduce the errors of curvature and torsion compared to conventional SFM. We then apply the present SFM to the centerline of the SG in an abdominal aortic aneurysm (AAA), and those of bilateral internal carotid arteries (ICA) in 6 cases: 3 cases with aneurysms and 3 cases without any aneurysm. The SG centerlines were obtained from temporal medical images at three scan times. The strong peak of the curvature could be clearly observed in the distal area of the SG, the inversion of the torsion at 0 months in the middle area of SG disappeared over time, and the torsions around the SG bifurcation at the three time periods were inverted. The curvature-torsion graphs along the ICA centerlines superimposing five aneurysmal positions were useful for investigating the relationship between arterial bending structure and aneurysmal positions. Both ICAs had curvature peak values higher than 0.4 within the ICA syphons. The ICA torsion graphs indicated that left and right ICA tended to be a right- and left-handed helix, respectively. In the left ICA syphon, the biggest aneurysm could be observed downstream of the salient torsion inversion. All aneurysms for 3 cases were positioned at the downstream of the inverted torsion.
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Affiliation(s)
- Masaharu Kobayashi
- Graduate School of Interdisciplinary Information Studies, The University of Tokyo, 4-6-1 Komaba, Meguro-ku, Tokyo 153-8505, Japan.
| | - Katsuyuki Hoshina
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Youkou Nemoto
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Shu Takagi
- Department of Mechanical Engineering, Graduate School of Engineering, The University of Tokyo, Bunkyo, Tokyo 113-8656, Japan.
| | - Masaaki Shojima
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Motoharu Hayakawa
- Department of Neurosurgery, Fujita Health University, 1-98 Kengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192, Japan.
| | - Shigeki Yamada
- Department of Neurosurgery, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga 520-2192, Japan.
| | - Marie Oshima
- Interfaculty in Information Studies/Institute of Industrial Science, The University of Tokyo, 4-6-1 Komaba, Meguro-ku, Tokyo 153-8505, Japan.
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Hwang D, Kim J, Kim HK, Huh S. Suitability of the Aortic Neck Anatomy for Endovascular Aneurysm Repair in Korean Patients with Abdominal Aortic Aneurysm. Vasc Specialist Int 2020; 36:71-81. [PMID: 32611839 PMCID: PMC7333089 DOI: 10.5758/vsi.200016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/09/2020] [Accepted: 05/18/2020] [Indexed: 11/27/2022] Open
Abstract
Purpose To evaluate the aortic neck anatomy in Korean patients with abdominal aortic aneurysms (AAAs). Materials and Methods We examined computed tomography scans of 343 patients with AAAs (≥5.5 cm for men or ≥5 cm for women) between 2009 and 2018. Eligibility of neck anatomy for endovascular aneurysm repair (EVAR) was assessed with the standard instructions for use (IFU) (length ≥15 mm, suprarenal angulation (SRA) ≤45°, infrarenal angulation (IRA) ≤60°, and diameter 18-32 mm) and the extended IFU (length ≥10 mm, SRA ≤60°, IRA ≤75°, and diameter 17-32 mm). Results There were 71 women (20.7%), and 61 patients (17.8%) with rupture. Women had smaller neck diameters (21.3 vs. 23.4 mm, P<0.001 for proximal neck; 22.2 vs. 24.5 mm, P<0.001 for distal neck), and higher angulations (51.5° vs. 37.8°, P<0.001 for SRA; 77.7° vs. 57.0°, P<0.001 for IRA) than men. However, the neck length was not significantly different. Patients with ruptured AAAs had shorter neck lengths (21.0 vs. 26.8 mm, P=0.005) than those with intact AAAs. However, the neck diameters and angulations were not significantly different. EVAR eligibility for standard and extended IFUs was found in 37.5% and 55.1% of men, and 11.3% and 25.4% of women (P<0.001 for both IFUs); neck anatomy was eligible in 34.0% of intact AAAs and 23.0% of ruptured AAAs (P=0.098). Conclusion A significant proportion of the Korean patients did not meet the IFU for EVAR, mainly due to the angulated neck. Women, and patients with ruptured AAAs, were less likely to meet the IFU criteria.
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Affiliation(s)
- Deokbi Hwang
- Division of Vascular Surgery, Department of Surgery, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jihye Kim
- Division of Vascular Surgery, Department of Surgery, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyung-Kee Kim
- Division of Vascular Surgery, Department of Surgery, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seung Huh
- Division of Vascular Surgery, Department of Surgery, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
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Fatima J, Tenorio ER, Oderich GS. Anatomical aspects and feasibility of endovascular repair for chronic post-dissection arch and thoracoabdominal aortic aneurysms. J Cardiovasc Surg (Torino) 2020; 61:385-391. [PMID: 32337942 DOI: 10.23736/s0021-9509.20.11405-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Aortic dissection is a complex pathology that carries significant morbidity and mortality if not treated in a timely fashion. While the open repair remains the gold standard treatment for patients with acute type A dissection, ascending aortic replacement is associated with high incidence of arch and descending thoracic aorta residual false lumen patency and aneurysmal degeneration. Multiple approaches have been used over the decades to address aneurysmal degeneration in the arch and thoracoabdominal aorta. This article summarizes anatomical requirements for total endovascular repair of aortic arch and TAAAs using fenestrated and branched endografts.
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Affiliation(s)
- Javairiah Fatima
- Department of Vascular Surgery, MedStar Heart and Vascular Institute, Washington DC, USA -
| | - Emanuel R Tenorio
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Mascia D, Bertoglio L, Kahlberg AL, Grandi A, Melissano G, Chiesa R. Open Repair of Proximal Abdominal Aneurysms Analyzed According to the Anatomy, Clamping Site, and Theoretical Fenestrated Endovascular Design. Ann Vasc Surg 2020; 63:83-91. [DOI: 10.1016/j.avsg.2019.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/02/2019] [Accepted: 07/07/2019] [Indexed: 10/26/2022]
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Hoshina K, Ishimaru S, Sasabuchi Y, Yasunaga H, Komori K; Japan Committee for Stentgraft Management (JACSM)*. Outcomes of Endovascular Repair for Abdominal Aortic Aneurysms: A Nationwide Survey in Japan. Ann Surg 2019; 269:564-73. [PMID: 28885502 DOI: 10.1097/SLA.0000000000002508] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To analyze data on patients treated with a bifurcated stent graft for abdominal aortic aneurysm (AAA). BACKGROUND The Japan Committee for Stentgraft Management (JACSM) was established in 2007 to manage the safety of endovascular aortic aneurysm repair (EVAR) in Japan. The JACSM registry includes detailed anatomical and clinical data of all patients who undergo stent graft insertion in Japan. METHODS Among 51,380 patients treated with bifurcated stent graft for AAA, we identified 38,008 eligible patients (excluding those with rupture or insufficient data). The analyzed factors included age, sex, comorbidities, AAA pathology and etiology, aneurysm and neck diameters, 7 anti-instructions for use (IFU) factors, and endoleaks at hospital discharge. The endpoints were death, adverse events, sac dilatation (≥5 mm), and reintervention. RESULTS The rates of intraoperative and in-hospital mortality were 0.08% and 1.07%, respectively. Infectious aneurysm and pseudo-aneurysm were associated with overall survival and reintervention. Older age, large aneurysm diameter, and all types of persistent endoleaks were strong predictors of adverse events, sac dilatation, and reintervention. Comorbid cerebrovascular disease, renal dysfunction, and respiratory disorders were also risk factors. In total, 47.6% of patients violated the IFU; among the anti-IFU factors assessed, poor access and severe neck calcification were strong risk factors for mortality, reintervention, and adverse events. The sac dilatation rate at 5 years was 23.3%. CONCLUSIONS Although the analysis included EVAR with poor anatomy, the perioperative mortality rate was acceptable compared with that in previous large population studies.
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Charbonneau P, Hongku K, Herman CR, Habib M, Girsowicz E, Doonan RJ, Dubois L, Hossain S, Gill HL, Mackenzie KS, Bayne JP, Obrand D, Steinmetz OK. Long-term survival after endovascular and open repair in patients with anatomy outside instructions for use criteria for endovascular aneurysm repair. J Vasc Surg 2019; 70:1823-1830. [DOI: 10.1016/j.jvs.2019.01.081] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 01/19/2019] [Indexed: 10/26/2022]
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Simons JP, Podder S, Dossabhoy SS, Wyman AS, Arous EJ, Judelson DR, Aiello FA, Schanzer A. Fenestrated/Branched Endovascular Aortic Aneurysm Repair Using a Supraceliac Aortic Proximal Seal Zone Versus an Infraceliac Aortic Proximal Seal Zone. Ann Vasc Surg 2020; 62:213-22. [PMID: 31382008 DOI: 10.1016/j.avsg.2019.04.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/08/2019] [Accepted: 04/30/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Fenestrated/branched endovascular aneurysm repair (F/B-EVAR) achieves more extensive proximal seal than conventional infrarenal devices, thereby increasing aneurysm exclusion durability. Optimal seal zone length remains undefined. We assessed relative risks and benefits of extending the proximal seal above the celiac artery. METHODS The prospective database of all complex endovascular aortic aneurysm repairs at a single institution (institutional review board-approved, physician-sponsored investigational device exemption trial, 10/2010-6/2017) was used to classify repairs according to the number of target visceral-renal arteries incorporated: 4-vessel versus <4-vessel. Comparisons of aneurysm characteristics, perioperative details, and postoperative complications were performed, stratified by repair type. One-year survival, target artery patency, freedom from type 1 or 3 endoleak, and freedom from reintervention were estimated with Kaplan-Meier analysis. RESULTS Among 175 F/B-EVARs, 38% (n = 67) were 4-vessel and 62% (n = 108) were <4-vessel. Intraoperatively, there was no difference in mean contrast use (76 mL vs. 74 mL, P = non significant [NS]) or dose area product (63,428 mGy cm2 vs. 96,015 mGy cm2), but there was increased median procedure time (4.8 hr, interquartile range [IQR] = 4.1-5.8 versus 3.6 hr, IQR = 2.9-4.1, P < 0.0001) and mean operating room direct costs ($52,532, standard deviation [SD] = 18,640 versus $40,128, SD = 15,135, P < 0.0001) in 4-vessel repairs. There were no differences in mortality (1.9% vs. 4.5%), paraparesis (0% vs. 3.0%), or paralysis (0.9% vs. 0%), all P = NS. There were no differences in one-year survival, target artery patency, or freedom from reintervention. There was a lower 1-year freedom from type 1 or 3 endoleak with 4-vessel repairs (82% vs. 94%, log-rank P = 0.02), driven by an increased rate of type 3 endoleaks. Endoleak resolution after treatment was equivalent in both groups (4-vessel, 10 of 12, 83% resolved; <4-vessel, 7 of 7, 100% resolved, P = NS). CONCLUSIONS With F/B-EVAR, utilization of a supraceliac seal zone, compared with an infraceliac seal zone, is associated with statistical differences in operative characteristics/resource utilization, but with negligible clinical significance. Further innovation to eliminate type 3 endoleaks at fenestrations/branches remains an unmet need. To achieve adequate F/B-EVAR proximal seal zone length, one should have a low threshold to incorporate the celiac artery.
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Nolz R, Schoder M, Baltzer P, Prusa A, Javor D, Loewe C, Asenbaum U. Application of Baseline Clinical and Morphological Parameters for Prediction of Late Stent Graft Related Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg 2019; 58:24-32. [PMID: 31160189 DOI: 10.1016/j.ejvs.2018.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 11/05/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To evaluate the influence of baseline clinical and morphological parameters on the occurrence of a late stent graft related endoleak (srEL; types 1 and 3) after endovascular aneurysm repair (EVAR). METHODS This is a retrospective case control study of patients who were routinely followed up after EVAR of abdominal aortic aneurysms. Pre-interventional, pre-discharge, and last available multislice computed tomography angiogram (MSCTA) of 279 patients were analysed. Stent graft related endoleaks detected by follow up MSCTA at least six months after EVAR were specified as late srEL. Baseline demographic characteristics and morphological variables were derived from the pre-interventional and pre-discharge MSCTA. Univariable and multivariable analysis with a Cox proportional hazards model were used to determine baseline factors associated with the occurrence of a late srEL. RESULTS Twenty-four (8.6%) of 279 patients suffered a late srEL, during a mean MSCTA follow up of 30.9 ± 25.8 (23.5, IQR 10.6-42.8) months. In the univariable analysis, age (hazard ratio [HR] 1.09; p = .001), female sex (HR 3.25; p = .014), right iliac sealing diameter (HR 10.04; p = .03), left iliac sealing diameter (HR 8.65; p = .001), infrarenal aortic neck angulation (HR 1.02; p = .011), and suprarenal fixation level (HR 3.47; p = .014) were significantly associated with an increased incidence of late srEL. Age (HR 1.08; p = .012), female sex (HR 2.72; p = .049), and left iliac sealing diameter (HR 4.48; p = .033) proved to be risk factors significantly associated with a higher incidence of late srEL in multivariable analysis. CONCLUSIONS Older patients, those with female gender, and those with larger left iliac sealing diameters seem to experience higher rates of late srEL. Independent confirmation of these must be addressed in larger studies.
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Affiliation(s)
- Richard Nolz
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria
| | - Maria Schoder
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria
| | - Pascal Baltzer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria
| | - Alexander Prusa
- Department of Vascular Surgery, Medical University of Vienna, Austria
| | - Domagoj Javor
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria
| | - Christian Loewe
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria
| | - Ulrika Asenbaum
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria.
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Brazzelli M, Hernández R, Sharma P, Robertson C, Shimonovich M, MacLennan G, Fraser C, Jamieson R, Vallabhaneni SR. Contrast-enhanced ultrasound and/or colour duplex ultrasound for surveillance after endovascular abdominal aortic aneurysm repair: a systematic review and economic evaluation. Health Technol Assess 2019; 22:1-220. [PMID: 30543179 DOI: 10.3310/hta22720] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Endovascular abdominal aortic aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) is less invasive than open surgery, but may be associated with important complications. Patients receiving EVAR require long-term surveillance to detect abnormalities and direct treatments. Computed tomography angiography (CTA) has been the most common imaging modality adopted for EVAR surveillance, but it is associated with repeated radiation exposure and the risk of contrast-related nephropathy. Colour duplex ultrasound (CDU) and, more recently, contrast-enhanced ultrasound (CEU) have been suggested as possible, safer, alternatives to CTA. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of imaging strategies, using either CDU or CEU alone or in conjunction with plain radiography, compared with CTA for EVAR surveillance. DATA SOURCES Major electronic databases were searched, including MEDLINE, EMBASE, Science Citation Index, Scopus' Articles-in-Press, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE) and NHS Economic Evaluation Database from 1996 onwards. We also searched for relevant ongoing studies and conference proceedings. The final searches were undertaken in September 2016. METHODS We conducted a systematic review of randomised controlled trials and cohort studies of patients with AAAs who were receiving surveillance using CTA, CDU and CEU with or without plain radiography. Three reviewers were involved in the study selection, data extraction and risk-of-bias assessment. We developed a Markov model based on five surveillance strategies: (1) annual CTA; (2) annual CDU; (3) annual CEU; (4) CDU together with CTA at 1 year, followed by CDU on an annual basis; and (5) CEU together with CTA at 1 year, followed by CEU on an annual basis. All of these strategies also considered plain radiography on an annual basis. RESULTS We identified two non-randomised comparative studies and 25 cohort studies of interventions, and nine systematic reviews of diagnostic accuracy. Overall, the proportion of patients who required reintervention ranged from 1.1% (mean follow-up of 24 months) to 23.8% (mean follow-up of 32 months). Reintervention was mainly required for patients with thrombosis and types I-III endoleaks. All-cause mortality ranged from 2.7% (mean follow-up of 24 months) to 42% (mean follow-up of 54.8 months). Aneurysm-related mortality occurred in < 1% of the participants. Strategies based on early and mid-term CTA and/or CDU and long-term CDU surveillance were broadly comparable with those based on a combination of CTA and CDU throughout the follow-up period in terms of clinical complications, reinterventions and mortality. The economic evaluation showed that a CDU-based strategy generated lower expected costs and higher quality-adjusted life-year (QALYs) than a CTA-based strategy and has a 63% probability of being cost-effective at a £30,000 willingness-to-pay-per-QALY threshold. A CEU-based strategy generated more QALYs, but at higher costs, and became cost-effective only for high-risk patient groups. LIMITATIONS Most studies were rated as being at a high or moderate risk of bias. No studies compared CDU with CEU. Substantial clinical heterogeneity precluded a formal synthesis of results. The economic model was hindered by a lack of suitable data. CONCLUSIONS Current surveillance practice is very heterogeneous. CDU may be a safe and cost-effective alternative to CTA, with CTA being reserved for abnormal/inconclusive CDU cases. FUTURE WORK Research is needed to validate the safety of modified, more-targeted surveillance protocols based on the use of CDU and CEU. The role of radiography for surveillance after EVAR requires clarification. STUDY REGISTRATION This study is registered as PROSPERO CRD42016036475. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pawana Sharma
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Clare Robertson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Giudice R, Borghese O, Sbenaglia G, Coscarella C, De Gregorio C, Leopardi M, Pogany G. The use of EndoAnchors in endovascular repair of abdominal aortic aneurysms with challenging proximal neck: Single-centre experience. JRSM Cardiovasc Dis 2019; 8:2048004019845508. [PMID: 31041098 PMCID: PMC6484241 DOI: 10.1177/2048004019845508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 01/15/2019] [Accepted: 01/28/2019] [Indexed: 12/05/2022] Open
Abstract
Objectives The aim of this study was to present a single-centre experience with
EndoAnchors in patients who underwent endovascular repair for abdominal
aortic aneurysms with challenging proximal neck, both in the prevention and
treatment of endograft migration and type Ia endoleaks. Methods We retrospectively analysed 17 consecutive patients treated with EndoAnchors
between June 2015 and May 2018 at our institution. EndoAnchors were applied
during the initial endovascular aneurysm repair procedure (primary implant)
to prevent proximal neck complications in difficult anatomies (nine
patients), and in the follow-up after aneurysm exclusion (secondary implant)
to correct type Ia endoleak and/or stent-graft migration (eight
patients). Results Mean time for anchors implant was 23 min (range 12–41), with a mean of 5
EndoAnchors deployed per patient. Six patients in the secondary implant
group required a proximal cuff due to stent-graft migration ≥10 mm.
Technical success was achieved in all cases, with no complications related
to deployment of the anchors. At a median follow-up of 13 months (range
4–39, interquartile range 9–20), there were no aneurysm-related deaths or
aneurysm ruptures, and all patients were free from reinterventions. CT-scan
surveillance showed no evidence of type Ia endoleak, anchors dislodgement or
stent-graft migration, with a mean reduction of aneurysm diameter of 0.4 mm
(range 0–19); there was no sac growth or aortic neck enlargement in any
case. Conclusions EndoAnchors can be safely used in the prevention and treatment of type Ia
endoleaks in patients with challenging aortic necks, with good results in
terms of sac exclusion and diameter reduction in the mid-term follow-up.
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Affiliation(s)
- Rocco Giudice
- Department of Vascular and Endovascular Surgery, "S. Giovanni-Addolorata" Hospital, Rome, Italy
| | - Ottavia Borghese
- Department of Vascular and Endovascular Surgery, "S. Giovanni-Addolorata" Hospital, Rome, Italy
| | - Giorgio Sbenaglia
- Department of Vascular and Endovascular Surgery, "S. Giovanni-Addolorata" Hospital, Rome, Italy
| | - Carlo Coscarella
- Department of Vascular and Endovascular Surgery, "S. Giovanni-Addolorata" Hospital, Rome, Italy
| | - Claudia De Gregorio
- Department of Vascular and Endovascular Surgery, "S. Giovanni-Addolorata" Hospital, Rome, Italy
| | - Marco Leopardi
- Department of Vascular and Endovascular Surgery, "S. Salvatore" Hospital, L'Aquila, Italy
| | - Gabriele Pogany
- Department of Vascular and Endovascular Surgery, "S. Giovanni-Addolorata" Hospital, Rome, Italy
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Shutze W, Suominen V, Jordan W, Cao P, Oweida S, Milner R. The incidence and effect of noncylindrical neck morphology on outcomes after endovascular aortic aneurysm repair in the Global Registry for Endovascular Aortic Treatment. J Vasc Surg 2018; 68:1714-24. [DOI: 10.1016/j.jvs.2018.03.394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 03/09/2018] [Indexed: 11/20/2022]
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Goudeketting SR, van Noort K, Ouriel K, Jordan WD, Panneton JM, Slump CH, de Vries JPP. Influence of aortic neck characteristics on successful aortic wall penetration of EndoAnchors in therapeutic use during endovascular aneurysm repair. J Vasc Surg 2018; 68:1007-1016. [DOI: 10.1016/j.jvs.2018.01.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 01/15/2018] [Indexed: 10/28/2022]
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Francois CJ, Skulborstad EP, Majdalany BS, Chandra A, Collins JD, Farsad K, Gerhard-Herman MD, Gornik HL, Kendi AT, Khaja MS, Lee MH, Sutphin PD, Kapoor BS, Kalva SP. ACR Appropriateness Criteria ® Abdominal Aortic Aneurysm: Interventional Planning and Follow-Up. J Am Coll Radiol 2018; 15:S2-S12. [DOI: 10.1016/j.jacr.2018.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 12/17/2022]
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Kansagra K, Kang J, Taon MC, Ganguli S, Gandhi R, Vatakencherry G, Lam C. Advanced endografting techniques: snorkels, chimneys, periscopes, fenestrations, and branched endografts. Cardiovasc Diagn Ther 2018; 8:S175-S183. [PMID: 29850429 DOI: 10.21037/cdt.2017.08.17] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The anatomy of aortic aneurysms from the proximal neck to the access vessels may create technical challenges for endovascular repair. Upwards of 30% of patients with abdominal aortic aneurysms (AAA) have unsuitable proximal neck morphology for endovascular repair. Anatomies considered unsuitable for conventional infrarenal stent grafting include short or absent necks, angulated necks, conical necks, or large necks exceeding size availability for current stent grafts. A number of advanced endovascular techniques and devices have been developed to circumvent these challenges, each with unique advantages and disadvantages. These include snorkeling procedures such as chimneys, periscopes, and sandwich techniques; "homemade" or "back-table" fenestrated endografts as well as manufactured, customized fenestrated endografts; and more recently, physician modified branched devices. Furthermore, new devices in the pipeline under investigation, such as "off-the-shelf" fenestrated stent grafts, branched stent grafts, lower profile devices, and novel sealing designs, have the potential of solving many of the aforementioned problems. The treatment of aortic aneurysms continues to evolve, further expanding the population of patients that can be treated with an endovascular approach. As the technology grows so do the number of challenging aortic anatomies that endovascular specialists take on, further pushing the envelope in the arena of aortic repair.
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Affiliation(s)
- Kartik Kansagra
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Joseph Kang
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | | | - Suvranu Ganguli
- Division of Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ripal Gandhi
- Division of Vascular and Interventional Radiology, Miami Cardiac and Vascular Institute, Miami, FL, USA
| | | | - Cuong Lam
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
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Tadros RO, Sher A, Kang M, Vouyouka A, Ting W, Han D, Marin M, Faries P. Outcomes of using endovascular aneurysm repair with active fixation in complex aneurysm morphology. J Vasc Surg 2018; 68:683-692. [PMID: 29548813 DOI: 10.1016/j.jvs.2017.12.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 12/12/2017] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The ideal treatment option for patients with complex aneurysm morphology remains highly debated. The aim of this study was to investigate the impact of endovascular aneurysm repair (EVAR) with active fixation on outcomes in patients with complex aneurysm morphology. METHODS There were 340 consecutive patients who underwent EVAR using active fixation devices, 234 with active infrarenal fixation (AIF; Gore Excluder; W. L. Gore & Associates, Flagstaff, Ariz) and 106 with active suprarenal fixation (ASF; 85 Medtronic Endurant [Medtronic, Santa Rosa, Calif] and 21 Cook Zenith [Cook Medical, Bloomington, Ind]). Demographics, comorbidities, anatomic features, and outcomes were analyzed for patients receiving devices with active fixation. Outcomes of using active fixation in necks with <15-mm neck lengths, >60-degree infrarenal neck angle (β), >30-mm infrarenal neck diameter, severe aortic neck calcification or thrombus, and nonstraight neck morphology were evaluated. RESULTS Of the 340 patients, 106 (78 men; mean age, 74.5 ± 9.3 years at the time of surgery) received implants with ASF and 234 (191 men; mean age, 74.6 ± 8.9 years at the time of surgery) received implants with AIF. In comparing AIF and ASF devices, patients in the suprarenal fixation group had significantly shorter follow-up time (25 ± 17 months vs 44.3 ± 32 months; P < .0001). Patients in the ASF group had shorter aortic neck lengths (25.5 ± 15.1 mm vs 28.6 ± 14.9 mm; P = NS) and significantly larger infrarenal neck diameters (25.9 ± 6.3 mm vs 23.4 ± 3.2 mm; P < .0001) and aneurysm diameters (59.9 ± 11.6 mm v. 55.9 ± 10.0 mm; P = .002). Outcomes were similar between groups, with no significant differences in reintervention, proximal endoleak, sac growth, abdominal aortic aneurysm-related death, or rupture. Of the complex anatomic neck features investigated, neck diameter >30 mm and nonstraight neck morphology had the highest rates of reintervention in ASF devices. CONCLUSIONS In cases of hostile infrarenal neck morphology, ASF appears to be used more frequently. Our data suggest that ASF may be useful for certain patients but may be unfavorable for others, such as those with wide necks or several difficult neck features. Nevertheless, further research is needed to evaluate more optimal treatment options, such as fenestrated EVAR, branched EVAR, and endovascular adjuncts such as EndoAnchors (Aptus Endosystems, Sunnyvale, Calif), in dealing with high-risk anatomic characteristics that may not be optimally managed with standard EVAR devices with active fixation.
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Affiliation(s)
- Rami O Tadros
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Alex Sher
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Martin Kang
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ageliki Vouyouka
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Windsor Ting
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Daniel Han
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael Marin
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter Faries
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Manunga J, Sullivan T, Garberich R, Alden P, Alexander J, Skeik N, Titus J, Stephenson E, Cragg A. Single-center experience with complex abdominal aortic aneurysms treated by open or endovascular repair using fenestrated/branched endografts. J Vasc Surg 2018; 68:337-47. [PMID: 29510915 DOI: 10.1016/j.jvs.2017.11.093] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 11/19/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate outcomes of patients with complex abdominal aortic aneurysms (cAAAs) treated with open repair (OR) or fenestrated/branched endovascular aneurysm repair (F/B-EVAR) from a single center. METHODS A retrospective analysis of consecutive patients with cAAAs treated electively by OR or F/B-EVAR between January 2010 and February 2017 was conducted. Demographics of the patients, cardiovascular risk factors, procedure time, number of vessels incorporated, radiation dose, estimated blood loss, intensive care unit (ICU) length of stay (LOS), and hospital LOS were recorded. End points included target vessel patency, aneurysm rupture, freedom from reintervention, and major adverse events (MAEs). RESULTS During this period, 153 patients (OR, 69; F/B-EVAR, 84) underwent repair of cAAA. The majority were male (OR, 55; F/B-EVAR, 64), with a mean age of 75.8 ± 7.6 years (F/B-EVAR) and 71.2 ± 7.9 years (OR). Patients in the F/B-EVAR group were more likely to be American Society of Anesthesiologists class 3 and 4 (60% vs 0%; P < .001) and had a higher median Society for Vascular Surgery/American Association for Vascular Surgery comorbidity severity score (15 vs 7; P < .001). A total of 235 vessels were targeted in the F/B-EVAR group, with a technical success of 97.6%. Thirty-one patients in the OR group required concomitant renal artery revascularization. Transfusion requirements (100% vs 1.2%), MAEs (40.6% vs 13.1%), procedure length (304 minutes vs 140 minutes), estimated blood loss (2246 mL vs 165 mL), ICU LOS (3 days vs 1 day), and hospital LOS (7 days vs 2 days) were higher (P < .001) in the OR group compared with the F/B-EVAR group. The 30-day mortality was 2.9% and 2.4% (P = .84) in the OR group and F/B-EVAR group, respectively. Supraceliac clamp site was associated with increased incidence of postoperative renal insufficiency. A decrease in procedure time, contrast volume, fluoroscopy time, and fluoroscopy dose was noted in the F/B-EVAR group with increasing experience even as case complexity increased. More patients were discharged home after F/B-EVAR (97.6% vs 59.4%; P < .001). With a mean follow-up of 31 months (F/B-EVAR, 17 months; OR, 48 months), the rate of secondary intervention was 3.7% and 5.8% (P = NS) for F/B-EVAR and OR, respectively. Freedom from branch instability and reintervention was 99% (95% confidence interval, 96.2%-99.8%) and 96% (95% confidence interval, 87.1%-98.6%), respectively. CONCLUSIONS Results of this "real-world" experience suggest that the use of F/B-EVAR for the treatment of cAAAs in high-risk surgical patients is safe and effective and has comparable short-term results to those of low-risk patients undergoing OR. Patients treated by F/B-EVAR had shorter ICU and hospital LOS, lower MAEs, and faster convalescence. A decrease in procedure time and radiation dose was noted as experience was gained, even as complexity increased.
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Karathanos C, Spanos K, Kouvelos G, Athanasoulas A, Koutsias S, Matsagkas M, Giannoukas AD. Hostility of proximal aortic neck anatomy in relation to abdominal aortic aneurysm size and its impact on the outcome of endovascular repair with the new generation endografts. J Cardiovasc Surg (Torino) 2018; 61:60-66. [PMID: 29327561 DOI: 10.23736/s0021-9509.18.10001-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND To assess the relation of abdominal aortic aneurysm (AAA) diameter with the proximal neck anatomy (PNA) hostility and to evaluate its impact on the endovascular aneurysm repair (EVAR) outcomes with the use of newer generation endografts. METHODS Retrospective analysis of single institution's recorded data from February 2009 to April 2016. Patients' characteristics, comorbidities, aortic morphology, perioperative characteristics and outcomes were analyzed. In relation to AAA diameter 2 groups were identified: group A (50-55 mm) and group B (>55 mm). Hostile PNA was defined based on: neck diameter >28 mm, length <15 mm, angulation >60o, and circumferential thrombus and/or calcification >50%. The aortic neck scoring system was calculated. Multiple logistic regression analysis with a forward likelihood ratio method adjusted for age and gender was undertaken. RESULTS Three hundred seventeen patients (96% males, mean age 72.4±9 years, 80% elective) were follow-up for a mean of 23.4 months (range, 3-86 months). No differences were observed in demographics and co-morbidities between the two groups (group A: 134, 42% vs. group B: 183, 58%). Hostile PNA was present in 147/317 (46%) patients and significantly more likely to be present in group B (P<0.001). In group B the aortic neck score was higher (P<0.001), the likelihood for having hostile PNA increased for neck diameter by 2.2-fold (OR 2.2, P=0.013, 95% CI: 1.18-4.03), length by 2.3-fold (OR 2.3, P=0.012, 95% CI: 1.20-4.51), angle by 4.8-fold (OR 4.8, P=0.002, 95% CI: 1.79-13.24) and presence of thrombus by 1.5-fold (OR 1.5, P=0.037, 95% CI: 1.45-10.34). No association existed for neck calcification (P=0.071). Technical success, adjunctive procedures, perioperative characteristics and outcomes were comparable in friendly and hostile PNAs. CONCLUSIONS PNA hostility is more likely in AAA with diameter >55 mm but with the use of newer generation endografts this did not influence the short- and mid-term EVAR outcomes. Longer follow-up is needed for a more definite conclusion.
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Affiliation(s)
- Christos Karathanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece -
| | - Konstantinos Spanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Athanasios Athanasoulas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Stylianos Koutsias
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
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Herman CR, Charbonneau P, Hongku K, Dubois L, Hossain S, Lee K, Steinmetz OK. Any nonadherence to instructions for use predicts graft-related adverse events in patients undergoing elective endovascular aneurysm repair. J Vasc Surg 2018; 67:126-133. [DOI: 10.1016/j.jvs.2017.05.095] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 05/02/2017] [Indexed: 10/19/2022]
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Jeon YS, Cho YK, Song MG, Seo TS, Kim JH, Song SY, Lee SY. Clinical Outcomes of Endovascular Aneurysm Repair with the Kilt Technique for Abdominal Aortic Aneurysms with Hostile Aneurysm Neck Anatomy: A Korean Multicenter Retrospective Study. Cardiovasc Intervent Radiol 2017; 41:554-563. [PMID: 29279976 DOI: 10.1007/s00270-017-1867-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 12/14/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE We aimed to evaluate the clinical efficacy and short-term clinical outcomes of Kilt technique-based endovascular aneurysm repair (EVAR) with Seal® stent-grafts for abdominal aortic aneurysms (AAAs) with hostile neck anatomy (angle > 60°). MATERIALS AND METHODS We retrospectively evaluated the pre-EVAR and follow-up computed tomography angiography findings of 24 patients (mean age 71 ± 11 years; age range 32-87 years; mean follow-up 50 ± 12 months) with hostile neck AAAs treated between 2010 and 2015. Serial change in aneurysmal neck angle was calculated using a standardized protocol. Relationships between clinical variables and outcomes were evaluated using univariate and multivariate Cox analyses and mixed-model regression. In addition, the Kaplan-Meier method was used to assess the cumulative rates of survival, endoleak, and reintervention. RESULTS The primary technical success rate (success within 24 h after EVAR) was 100% (24/24). The survival rate was 96 ± 8% at 1 month, 6 months, 1 year, and 3 years, and 87 ± 18% at 5 years. Endoleaks occurred in three patients. Four reinterventions were performed in three patients; no surgical revisions were required. Causes of post-EVAR mortality included intracerebral hemorrhage at 14 days and rhabdomyolysis at 32 months. The most remarkable change after Kilt-based EVAR was an acute decrease in the neck angle, which was observed between the pre-EVAR and first follow-up visits (at 1 month) (P = 0.001). CONCLUSION Kilt-based EVAR with Seal® stent-grafts for AAAs with a severely angulated neck (angle > 60°) provided high technical success, low mortality, and low complication rates during short-term follow-up.
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Affiliation(s)
- Yong Sun Jeon
- Department of Radiology, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
| | - Young Kwon Cho
- Department of Radiology, Kangdong Seong-Sim Hospital, Hallym University College of Medicine, 150 Seongan-ro Gangdong-gu, Seoul, 134-701, Korea.
| | - Myung Gyu Song
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Tae-Seok Seo
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jeong Ho Kim
- Department of Radiology, Gachon University Gil Hospital, Gachon University College of Medicine, Incheon, Korea
| | - Soon-Young Song
- Department of Radiology, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Sam Yeol Lee
- Department of Surgery, Kangdong Seong-Sim Hospital, Hallym University College of Medicine, Seoul, Korea
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45
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Pitoulias GA, Valdivia AR, Hahtapornsawan S, Torsello G, Pitoulias AG, Austermann M, Gandarias C, Donas KP. Conical neck is strongly associated with proximal failure in standard endovascular aneurysm repair. J Vasc Surg 2017; 66:1686-95. [DOI: 10.1016/j.jvs.2017.03.440] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/23/2017] [Indexed: 11/22/2022]
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46
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Bannazadeh M, Jenkins C, Forsyth A, Kramer J, Aggarwal A, Somerset AE, Bove PG, Long GW. Outcomes for concomitant common iliac artery aneurysms after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2017; 66:1390-1397. [DOI: 10.1016/j.jvs.2017.02.058] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 02/23/2017] [Indexed: 12/11/2022]
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47
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Psacharopulo D, Ferri M, Ferrero E, Bahia SS, Viazzo A, Pecchio A, Ricceri F, Nessi F. Comparison of outcomes for short-neck and juxtarenal aortic aneurysms treated with the Nellix endograft versus conventional endovascular aneurysm sealing. J Vasc Surg 2017; 66:1371-1378. [DOI: 10.1016/j.jvs.2017.03.444] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 03/23/2017] [Indexed: 12/17/2022]
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Abstract
INTRODUCTION Current methods of teaching endovascular aortic aneurysm repair (EVAR) planning involve non-criteria-based observations that lack validity. The primary aim of this study was to validate an EVAR Planning Objective Structured Assessment of Skill (EpOSAS) tool for the assessment of pre-operative EVAR planning skills. METHODS Content analysis was performed in order to inform the formulation of EpOSAS domains. Thirty-five participants planned two cases of infra-renal abdominal aortic aneurysm for EVAR, using the OsiriX 7 platform. EVAR planning measurements, with accompanying screenshots, were uploaded onto an electronic data collection sheet. Performance was assessed by three blinded assessors using the EpOSAS tool. Construct and concurrent validity were evaluated. RESULTS Inter-observer reliability for the three assessors for total EpOSAS scores was high (Cronbach's α 0.89). There were statistically significant differences in total EpOSAS scores between the different experience groups, demonstrating construct validity (Novice (5.3, IQR 5-5.3), Intermediate (15.3, IQR 14.8-16.8) and Experts (17.5, IQR 17-17.7), p<0.001). A statistically significant correlation was found between total EpOSAS scores and percentage error in measurements, demonstrating concurrent validity (Spearman's rank correlation coefficient: R=-0.250, p<0.001). Receiver-operator characteristics analysis established a cut-off point of 16 out of 18 for determining competence. CONCLUSION We have developed and validated a tool that can be used for the assessment of pre-operative EVAR planning skills.
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Affiliation(s)
- Nikola Fatic
- 1 Department of Vascular Surgery, Clinical Centre of Montenegro, Podgorica, Montenegro
| | - Pasha Normahani
- 2 Department of Vascular Surgery, St Mary's Hospital, NHS Trust, Imperial College London, UK
| | - Dejan Mars
- 3 Department of Cardiology, Luton & Dunstable Hospital, NHS Trust, Luton, UK
| | - Nigel J Standfield
- 2 Department of Vascular Surgery, St Mary's Hospital, NHS Trust, Imperial College London, UK.,4 London Postgraduate School of Surgery, London, UK
| | - Usman Jaffer
- 2 Department of Vascular Surgery, St Mary's Hospital, NHS Trust, Imperial College London, UK
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Zettervall SL, Deery SE, Soden PA, Shean K, Siracuse JJ, Alef M, Patel VI, Schermerhorn ML. Editor's Choice - Renal complications after EVAR with suprarenal versus infrarenal fixation among all users and routine users. Eur J Vasc Endovasc Surg 2017; 54:287-293. [PMID: 28779856 PMCID: PMC5659342 DOI: 10.1016/j.ejvs.2017.05.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 05/18/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Previous studies comparing endografts with suprarenal and infrarenal fixation for endovascular abdominal aortic aneurysm repair (EVAR) have found conflicting results and did not account for differences in patient selection. This study aims to evaluate the differences in outcomes among surgeons who routinely use either suprarenal or infrarenal fixation, as well as all surgeons in the Vascular Study Group of New England (VSGNE). METHODS All patients undergoing EVAR in the VSGNE from 2003 to 2014 were identified. All ruptured aneurysms, repairs with concomitant procedures, and infrequently used stent grafts (<50) were excluded. Suprarenal endografts included Talent, Zenith, and Endurant; infrarenal endografts included AneuRx and Excluder. Grafts were compared among surgeons who used only one type of endograft (suprarenal or infrarenal) for >80% of cases, as well as all surgeons. Multivariate regression and Cox hazard models were utilised to account for patient demographics, comorbidities, operative differences, and procedure year. RESULTS This study identified 2574 patients (suprarenal, 1264; infrarenal, 1310) with 888 endografts placed by routine users (suprarenal, 409; infrarenal, 479). There were no differences in baseline comorbidities, including the estimated glomerular filtration rate, between suprarenal and infrarenal fixation, or between patients with endografts placed by routine and non-routine users. Patients treated with suprarenal endografts received more contrast than all users (102 mL vs. 100 mL, p = .01) and routine users (110 mL vs. 88 mL, p < .01), but other vascular and operative details were similar. Among all users, patients treated with suprarenal grafts had higher rates of creatinine increase >.5 mg/dL (3.7% vs. 2.0%, p = .01), length of stay >2 days (27% vs. 19%, p < .01), and discharge to a skilled nursing facility (9.2% vs. 6.7%, p = .02). There were no differences in 30 day or 1 year mortality. Following adjustment, suprarenal stent grafts remained associated with an increased risk of renal deterioration (OR 2.0; 95% CI 1.2-3.4) and prolonged length of stay (OR 1.8; 95% CI 1.4-2.2). Among routine users, suprarenal fixation was also associated with higher rates of renal dysfunction (3.7% vs. 1.3%, p = .02; OR 2.9; 95% CI 1.1-7.8). CONCLUSION Despite potential differences in patient selection, endografts with suprarenal fixation among all users and routine users were associated with higher rates of renal deterioration and longer length of hospital stay. Longer-term data are needed to determine the duration and severity of renal function decline and to identify potential benefits of decreased migration or endoleak.
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Affiliation(s)
- S L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Surgery, George Washington University, Washington, DC, USA
| | - S E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - P A Soden
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - K Shean
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - J J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA, USA
| | - M Alef
- Department of Surgery, Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT, USA
| | - V I Patel
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - M L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Koncar IB, Nikolic D, Milosevic Z, Ilic N, Dragas M, Sladojevic M, Markovic M, Filipovic N, Davidovic L. Morphological and Biomechanical Features in Abdominal Aortic Aneurysm with Long and Short Neck-Case-Control Study in 64 Abdominal Aortic Aneurysms. Ann Vasc Surg 2017; 45:223-230. [PMID: 28666818 DOI: 10.1016/j.avsg.2017.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/08/2017] [Accepted: 06/08/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Both, open and endovascular, procedures are related to higher complication rate in abdominal aortic aneurysm (AAA) with shorter neck. Previous study showed that long-neck AAA might have lower risk of rupture. Estimation of biomechanical forces in AAA improves rupture risk assessment. The aim of this study was to compare morphological features and biomechanical forces in the short- and long-neck AAA with threshold of 15 mm. METHODS Digital Imaging and Communication in Medicine images of 64 aneurysms were prospectively collected and analyzed in a case-control study. Using commercially available software, Peak wall Stress (PWS) and Rupture Risk Equivalent Diameter (RRED) were determined. Difference between the maximal aneurysm diameter (MAD) and RRED was calculated and expressed as an absolute and relative (percentage of the MAD) value. In addition, volume of intraluminal thrombus (ILT) was calculated and expressed relative to AAA volume. RESULTS Study included 64 AAA divided in group with long (36, 56.25%), and short (28, 43.75%) neck. There was no correlation between neck length and MAD, PWS, and RRED (P = 0.646, P = 0.421, and P = 0.405, respectively). Relative ILT volume was greater in the short-neck aneurysms (P = 0.033). Relative difference between RRED and MAD was -4% and -14.8% in short- and long-neck aneurysms, respectively (P = 0.029). The difference between RRED and MAD was positive in 14/28 patients (50%) with short neck and in 6/35 patients (17.14%) with long neck (P = 0.011). CONCLUSIONS Based on our biomechanical analysis, in AAA with neck longer than 15 mm rupture risk might be lower than the risk estimated by its diameter. It might be explained with lower relative volume of ILT.
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Affiliation(s)
- Igor B Koncar
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular surgery, Clinical Center of Serbia, Belgrade, Serbia.
| | - Dalibor Nikolic
- Research and Development Center for Bioengineering BioIRC, Kragujevac, Serbia; Faculty of Engineering, University of Kragujevac, Kragujevac, Serbia
| | - Zarko Milosevic
- Research and Development Center for Bioengineering BioIRC, Kragujevac, Serbia
| | - Nikola Ilic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Marko Dragas
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Milos Sladojevic
- Clinic for Vascular and Endovascular surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Miroslav Markovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Nenad Filipovic
- Research and Development Center for Bioengineering BioIRC, Kragujevac, Serbia; Faculty of Engineering, University of Kragujevac, Kragujevac, Serbia
| | - Lazar Davidovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Clinic for Vascular and Endovascular surgery, Clinical Center of Serbia, Belgrade, Serbia
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