Long-term outcomes and interventions of postoperative type 1a endoleak following elective endovascular aortic aneurysm repair

Perioperative and midterm outcomes of Branched or Fenestrated Endovascular Aneurysm Repair for type 1A endoleak after Endovascular Aneurysm Repair

INTRODUCTION AND AIM

The treatment of a failing Endovascular Aneurysm Repair (EVAR) due to loss of proximal sealing is challenging. Branched or Fenestrated Endovascular Aneurysm Repair (B/FEVAR) offer a promising endovascular solution. This study evaluates B/FEVAR outcomes for managing type 1A endoleak after EVAR.

PATIENT AND METHODS

All consecutive patients who underwent B/FEVAR surgery to treat a type 1A endoleak after EVAR at a large teaching hospital between 2019 and 2024 were included in this study. Outcomes analyzed included aneurysm-related mortality, overall survival, technical success, endoleaks, aneurysm sac dynamics, re-interventions, target vessel patency, target vessel instability, and other complications. Regular follow-up after B/FEVAR surgery included imaging at 1, 6, and 12 months and annually thereafter.

RESULTS

Among 24 patients (96% males, median age 73 (range: 66-80)), the median interval between EVAR and B/FEVAR was 6.6 years (range: 2-11). No aneurysm-related mortality was observed during follow-up. Median follow-up was 20 months (range: 3-67) and overall survival was 95%. The primary technical success rate was 88%, and the assisted primary technical success rate was 92%. Type 2 endoleaks were observed in 33% of patients, while type 3 endoleaks occurred in 13% of patients. Aneurysm sac regression during follow-up was reported in 17%, stabilization in 71% and expansion in 13% of patients. Re-interventions were required in 25% of patients. Primary target vessel patency and assisted primary target vessel patency were 95% and 97%. Target vessel instability was 8%.

CONCLUSION

B/FEVAR appears to be a safe, and effective option for managing type 1A endoleaks after prior EVAR based on midterm outcomes.

Secondary interventions and surveillance after elective abdominal aortic aneurysm repair

BACKGROUND

The early survival benefits of endovascular aneurysm repair (EVAR) appear to diminish over time, and late aneurysm-related mortality remains a significant concern. Our aim is to determine the rate of secondary interventions (SI) and assess compliance with post-EVAR surveillance.

METHODS

This retrospective cohort study included consecutive patients who underwent elective EVAR between February 2009 and May 2019 at a tertiary center. The primary outcomes were freedom from SI and compliance with follow-up (imaging performed within a time interval of no more than 18 months). Secondary outcome was overall patient survival.

RESULTS

A total of 214 patients underwent EVAR, with a median follow-up of 44 months. During this period, 42 SI were performed in 25 patients. Of all SI, 33.3% (14/42) were due to symptomatic complications. Freedom from SI was 96.3±1.3% at 30 days and 93.6±1.7%, 90.3±2.2% and 85.9±3.0 at 1, 3 and 5 years, respectively. Endoleaks were the main cause of SI after EVAR (N.=26), primarily type 1 and type 2. At 5 years, patient survival rates were similar (76.7±4.1% vs. 84.4±7.2%, P=0.386). Compliance with surveillance was 80.4±2.9% at 1 year, and 37.7±5.4% at 5 years.

CONCLUSIONS

SI after EVAR were frequent, with endoleaks being the leading cause and associated with cases of aneurysm sac rupture. Although compliance with surveillance decreases over longer follow-up periods, the impact of this trend on long-term outcomes after EVAR warrants further investigation.

Rupture after previous endovascular abdominal aortic aneurysm repair: A meta-analysis and meta-regression analysis of factors influencing perioperative mortality

OBJECTIVE

To document the clinical presentation, management, and outcome of patients presenting with late rupture of abdominal aortic aneurysm after previous endovascular aneurysm repair (EVAR) and to investigate which factors may influence the perioperative mortality.

METHODS

A systematic review and meta-analysis of relevant studies was undertaken to February 2024 in conformity with the PRISMA guidelines. We included studies reporting on either EVAR or open surgical repair (OSR) of late rupture (>30 days) after previous EVAR. The primary end point was perioperative (in-hospital or 30-day) mortality. A random effects meta-analysis was conducted and a meta-regression was subsequently performed to examine the impact of several variables on perioperative mortality.

RESULTS

Thirty studies (743 patients, 746 ruptures) were included. The cumulative incidence of rupture after EVAR during a mean 5-year follow-up was 1.5%. The mean time from the index EVAR to rupture was 48 months (range, 16-81 months). The mean compliance with follow-up was 68% (95% confidence interval [CI], 58-77) and 32% (95% CI, 24-40) of the cases had at least one previous aneurysm-related reintervention. Type I and III endoleaks were the predominant causes of rupture (88%). Approximately one-third of the patients (37%; 95% CI, 28-47) were hemodynamically unstable. Of those undergoing an operation, 247 patients (38%) were managed endovascularly and 409 (62%) by OSR. The pooled perioperative mortality was 29.5% (30 studies; 95% CI, 23.8-35.8) and was significantly lower in the endovascular subgroup (20 studies; risk ratio, 0.62; 95% CI, 0.44-0.86). Meta-regression demonstrated that perioperative mortality seems to fall in recent years (-0.0545; P = .04), to decrease in larger series in the endovascular subgroup (-0.0375; P = .01), and to be significantly higher when total endograft explantation is required in the OSR subgroup (0.0121; P = .03).

CONCLUSIONS

Late rupture after previous EVAR is a devastating event with a considerable risk for death. EVAR is associated with a significantly lower perioperative mortality and should be preferred whenever feasible. When OSR is required, total endograft explantation carries a higher mortality and, therefore, preserving functional parts of the endograft should be encouraged.

Prediction of Late Proximal Endoleak Risk after EVAR by Preoperative Estimation of Endograft/Aortic Neck Apposition Surface

BACKGROUND

The aim of this study was to evaluate a new measurement tool for the preoperative computed tomography (CT) scan to estimate the endograft apposition surface on the proximal aortic neck of the aneurysm that would predict the risk of late type IA endoleak (EL1A).

METHODS

From databases of 4 high-volume centers between 2004 and 2020, all patients who underwent Endovascular Aneuruysm Repair (EVAR) with the possibility of analyzing pre and post-EVAR scans and who presented late (>2 years) EL1A in follow-up were included retrospectively (EL1A group). A control group of randomly selected EL1A-free patients were included (control group) and followed-up beyond 4 years. The measurement tool (Endosize, Therenva) was used to model a virtual cylinder constrained by the centreline whose diameter was determined from the diameter of the implanted endograft. The apposition surface was calculated by determining the areas of the virtual cylinder mesh outside the mesh of the neighboring portion of the segmented aorta by an intersection calculation of surface normals. This apposition surface and the usual anatomical data of the proximal neck were compared between the groups with univariate and multivariate analyses. Intra and interobserver variability in the measurement of apposition surface was analyzed using the intraclass correlation coefficient (ICC) and the method of Bland and Altman.

RESULTS

Sixty-six comparable patients were included as follows: 33 in the EL1A group and 33 in the control group. The mean time to EL1A onset was 50.2 ± 24.6 months in the EL1A group, and the mean follow-up time was 79.8 ± 26.8 months in the control group. In univariate analysis, only the endograft apposition surface ratio on the proximal neck was significantly lower in the EL1A group compared with the control group (50.3% vs. 75.5%; P < 0.0001). There was no significant difference in classic anatomical neck characteristics. There was no difference in proximal endograft oversizing or in the length from the lowest renal artery to the beginning of the covered portion of the endograft. In multivariate analysis, only the apposition surface ratio was independently correlated with the presence of EL1A (P < 0.0001). The estimation of the intra and interobserver variability indicates excellent reliability (ICC = 0.992; ICC = 0.956).

CONCLUSIONS

The method estimating the preoperative endograft apposition surface on the proximal aortic neck appears to be a reliable measuring technique in predicting the risk of occurrence of late EL1A after EVAR.

Modified fenestrated/branched endovascular aortic repair with short bridging stent to treat complex aortic dissection

Objectives

This study aims to improve fenestrated/branched endovascular aortic repair (F/B EVAR) through fabricating physician-modified stent grafts (PMSG) with short bridging stent to treat complex aortic dissection.

Methods

From November 2018 to January 2024, a total of 82 aortic dissection patients were treated by F/B EVAR combined with short bridging stents, including 19 aortic arch dissection patients and 63 thoracoabdominal aortic dissection patients. Inner or outer short bridging stents were applied to fabricate PMSG with the help of 3D-printing models intraoperatively. All patients underwent postoperative evaluation by enhanced computed tomography in follow-up.

Results

All aortic dissections were successfully repaired. In aortic arch group, the average operative time was 289.2 ± 88.8 min. The perioperative mortality rate was 5.3%. The total reintervention rate was 5.3%. The average follow-up duration of 36.2 ± 9.5 months. The total incidence of endoleak after surgery was 15.8%. In thoracoabdominal aorta group, the average operative time was 345.5 ± 112.0 min. The perioperative mortality rate was 1.6%. The total reintervention rate was 1.6%. The average follow-up duration of 32.4 ± 19.2 months. The total incidence of endoleak after surgery was 11.1%.

Discussion

The application of short bridging stents has shown promising results in reducing endoleak rates after F/B EVAR. 3D-printing is a feasible way to assist the precise fenestration and design of short bridging stents. However, the safety and reliability of this method need to be further validated.

Risk factors of type 1A endoleak following endovascular aortic aneurysm repair

OBJECTIVES

Endovascular repair of infrarenal aortic aneurysms are the treatment of first choice. However, the proximal sealing of endovascular aneurysm repair is the Achilles' heel of the procedure. Insufficient proximal sealing can lead to endoleak type 1A and therefore expansion of the aneurysm sack and subsequent rupture.

METHODS

We performed a retrospective analysis of all consecutive patients with an infrarenal abdominal aneurysm treated with endovascular aneurysm repair. We studied whether demographic and anatomical features were risk factors for endoleak type 1A. Also, the results of different treatment strategies were described.

RESULTS

257 Patients were included in the study, most patients were male. In the multivariate analysis, female gender and infrarenal angulation were the most important risk factors for endoleak type 1A. Endoleak type 1A diagnosed at completion angiography disappeared in 77.8%. The occurrence of endoleak type 1A was associated with a higher risk of aneurysm-related mortality (p = 0.01).

CONCLUSION

Conclusions should be drawn with care, since the number of patients included in this study was small and there was a high incidence of patients lost to follow-up. This study suggests that endovascular aneurysm repair in female patients and patients with severe infrarenal angulation is associated with a higher risk of endoleak type 1A.

Late post-EVAR abdominal aortic aneurysm rupture: a meta-analysis study

This study presents updated information on post-endovascular aneurysm repair (EVAR) late aortic rupture (LAR) as the data in the literature are limited. It comprises a meta-analysis based on the recent evidence regarding the incidence, causes, treatment outcomes, and prognosis of post-EVAR. A meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were identified by searching electronic databases and scanning bibliographic references from 1991 to April 1, 2023. Our analysis provided evidence that the most common causes of rupture after EVAR were type Ia and Ib Endoleaks (Els). Post-rupture mortality after EVAR was high (35.6%) and comparable to the morbidity of de novo ruptures. Endovascular repair appears to have better results compared to conversion to open repair. A significant number of patients had prior endovascular reoperations and inadequate follow-up. Patient compliance with the surveillance protocol is mandatory.

Serious Failure Modes After EVAR Are Device Specific

OBJECTIVES

Type I and III endoleaks following endovascular aneurysm repair (EVAR) can lead to catastrophic events that require major re-interventions. We reviewed our experience with aortic endograft re-interventions for type I and III endoleaks and other serious failures among different devices.

METHODS

We retrospectively reviewed patients with a prior EVAR who underwent open conversion (OC) or major endovascular intervention (MEI) (re-lining, cuff/limb extension, parallel graft) for type I/III endoleaks at our institution from 2002 to 2019. Baseline characteristics, procedural details, re-interventions, and outcomes were collected.

RESULTS

A total of 229 patients (194 men) underwent re-interventions for type I and III endoleaks after EVAR (90 OC, 139 MEI) for devices implanted between 1997 and 2019. Average age at re-intervention was 78±8.5 years. A total of 135 (59%) were implanted at our institution, whereas 93 (41%) were referred. Median time to re-intervention was 4 years with 25% to 75% interquartile range (IQR) of 2.2-6.6 years. There was no significant difference in baseline demographics or type of re-interventions (OC/MEI) between device types. 42/229 (18%) presented with ruptured aneurysms, 20/229 (9%) were symptomatic, whereas the rest presented with asymptomatic radiographic findings. Type 1A endoleak was present in 146/229 (63.8%-72 with proximal migration), type IB in 46/229 (20.1%), type IIIA in 37/229 (16.6%), type IIIB in 15/229 (6.5%), and persistent aneurysm sac growth with no radiographic evidence of an endoleak in 6/229 (2.6%). Devices included most commercial products: AFX, Excluder, AneuRx, Ancure, Endurant, and Zenith. A smaller number of investigational devices accounted for the rest. Type 1A endoleak was the most common indication for re-intervention among all devices except for AFX and ancure devices, proximal migration was a frequent presentation with AneuRx. AFX devices more frequently presented with a type III and ancure devices more frequently presented with a type IB endoleak.

CONCLUSIONS

Serious failure modes after EVAR differ between endografts and occur throughout the follow-up period. This is important to guide targeted interrogation of surveillance studies and follow-up schedules, even for discontinued devices, as well as comparisons between various series and estimation of EVAR failure rates.

CLINICAL IMPACT

Surveillance after EVAR is critical for long term success of the repair, understanding of the differential modes of failure of every graft available is important in the longitudinal evaluation of these endografts. Equally important is the understanding of the modes of failure of legacy endografts that are no longer on the market but still being followed, in order to be able to tailor a surveillance regiemn and the evntual repair if needed.

A Greek Multicentre Study Assessing the Outcome of Late Rupture After Endovascular Abdominal Aortic Aneurysm Repair

OBJECTIVE

Late rupture after endovascular aortic aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) is an increasing complication associated with a high mortality rate. This study aimed to analyse the causes and outcomes in patients with AAA rupture after EVAR.

METHODS

A multi-institutional Greek study of late ruptures after EVAR between 2008 - 2022 was performed. Primary outcomes were intra-operative and in hospital death.

RESULTS

A total of 70 patients presented with late rupture after EVAR (proportion of ruptured EVARs among all EVARs, 0.6%; 69 males; mean age 77.2 ± 6.7 years). The mean time interval between EVAR and late rupture was 72.3 months (range 6 - 180 months). In all cases the cause of rupture was the presence of an endoleak (type I, 73%) with sac enlargement. Moreover, 34% of subjects with rupture after EVAR had been lost to follow up and 32% underwent a secondary intervention. Additionally, 57 patients (81%) were treated by conversion to open surgical repair (COSR) and the remainder by endovascular correction of endoleak (ECE). Eleven intra-operative deaths (16%) were recorded. The overall in hospital mortality rate was 41% (23% ECE vs. 46% COSR; p = .21). Of the patients who presented as initially haemodynamically stable, 23% died during hospitalisation, while the respective mortality rate for patients who presented as unstable was 78% (odds ratio [OR] 11.8, 95% confidence interval [CI] 3.6 - 39.1; p < .001). Multivariable logistic regression analysis revealed that severity of haemodynamic shock was the most significant risk factor for intra-operative (OR 7.15, 95% CI 1.58 - 32.40; p = .010) and in hospital death (OR 9.53, 95% CI 2.79 - 32.58; p < .001).

CONCLUSION

These data underline the devastating prognosis of late rupture after EVAR. Haemodynamic status at presentation was an important predictive factor for death both in the ECE and COSR groups. Rigorous follow up and prompt evaluation of an unstable patient in case of rupture after EVAR is recommended.

The Ratio Between the Infrarenal and Suprarenal Aortic Diameter Is a Predictor of Durable Proximal Seal After Endovascular Aneurysm Repair

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.

Selective aneurysmal sac neck-targeted embolization during endovascular repair of abdominal aortic aneurysm with hostile neck anatomy

PURPOSE

To evaluate the efficacy and safety of selective aneurysmal sac neck-targeted embolization in endovascular aneurysm repair (EVAR) in patients with a hostile neck anatomy (HNA).

MATERIALS AND METHODS

Between October 2020 and June 2022, patients with an abdominal aortic aneurysm (AAA) and HNA who underwent EVAR with a low-profile stent graft and a selective aneurysmal sac neck-targeted embolization technique were analysed. An HNA was defined by the presence of any of the following parameters: infrarenal neck angulation > 60°; neck length < 15 mm; conical neck; circumferential calcification ≥ 50%; or thrombus ≥ 50%. Before occluding the entire aneurysm during the procedure, a buddy wire was loaded prophylactically into the sac through the contralateral limb side. If a type Ia endoleak (ELIa) occurred and persisted despite adjunctive treatment such as balloon moulding or cuff extension, this preloaded wire could be utilized to enable a catheter to reach the space between the stent graft and sac neck to perform coil embolization. In the absence of ELIa, the wire was simply retracted. The primary outcome of this study was freedom from sac expansion and endoleak-related reintervention during the follow-up period; secondary outcomes included technical success and intraoperative and in-hospital postoperative complications.

RESULTS

Among the 28 patients with a hostile neck morphology, 11 (39.5%) who presented with ELIa underwent intraprocedural treatment involving sac neck-targeted detachable coil embolization. Seventeen individuals (60.7%) of the total patient population did not undergo coiling. All patients in the coiling group underwent balloon moulding, and 2 patients additionally underwent cuff extension. In the noncoiling group, 14 individuals underwent balloon moulding as a treatment for ELIa, while 3 patients did not exhibit ELIa during the procedure. The coiling group showed longer operating durations (81.27 ± 11.61 vs. 70.71 ± 7.17 min, P < 0.01) and greater contrast utilization than the noncoiling group (177.45 ± 52.41 vs. 108.24 ± 17.49 ml, P < 0.01). In the entire cohort, the technical success rate was 100%, and there were no procedure-related complications. At a mean follow-up of 18.6 ± 5.2 months (range 12-31), there were no cases of sac expansion (19 cases of sac regression, 67.86%; 9 cases of stability, 32.14%) or endoleak-related reintervention.

CONCLUSIONS

Selective aneurysmal sac neck-targeted embolization for the treatment of ELIa in AAA patients with an HNA undergoing EVAR is safe and may prevent type Ia endoleak and related sac expansion after EVAR.

Oversizing Consideration of Proximal Stent Graft in Hemodynamically Stable and Unstable Patients Undergoing Emergent Endovascular Aortic Repair

Consideration for oversizing the proximal stent graft is suggested in endovascular aortic repair. However, a special recommendation for the proximal oversizing ratio (OSR) in patients with ruptured abdominal aortic aneurysm (rAAA) is ambiguous. This study aims to evaluate the effect of different degrees of the proximal oversizing ratio (OSR) on risk of type IA endoleak (TIAEL) in hemodynamically stable and unstable patients with rAAA undergoing emergency endovascular aortic repair (EVAR). Our study included 134 rAAA patients undergoing emergent EVAR, and we did not observe a significant association between hemodynamic instability and risk of T1AEL (HR 3.89, 95%CI 0.40-37.75, p = 0.24). All three T1AELs in the hemodynamically unstable subgroup were observed in patients with OSR ≤ 30%, but no significant difference was found regarding T1AEL between patients with OSR > 30% and OSR ≤ 30% (0.00% vs. 11.11%, p = 0.19). As for hemodynamically stable patients, OSR > 20% was associated with a significantly decreased risk of T1AEL (HR 0.03, 95%CI 0.01-0.53, p = 0.016). In conclusion, a proximal OSR > 20% is associated with a decreased risk of T1AEL in hemodynamically stable patients, while an OSR > 30% did not add an additional advantage of lowering the risk of T1AEL in hemodynamically unstable patients.

Management of Endoleaks After Elective Infrarenal Aortic Endovascular Aneurysm Repair: A Review

Importance

Endovascular aneurysm repair (EVAR) is the dominant treatment strategy for abdominal aortic aneurysms, encompassing 80% of all repairs in the United States. Endoleaks are ubiquitous and affect 30% of patients treated by EVAR, potentially leading to sac enlargement and increased risk of rupture. The care of EVAR patients requires long-term surveillance by a multidisciplinary team. Accordingly, physicians should be familiar with the fundamentals of endoleak management to achieve optimal outcomes, including timely referral for remediation or providing counseling and reassurance when needed.

Observations

PubMed and the Cochrane database were searched for articles published between January 2002 and December 2022 in English, addressing epidemiology, diagnosis, and management of endoleaks after EVAR. Endoleaks can be detected intraoperatively or years later, making lifelong surveillance mandatory. Type I and III have the highest risk of rupture (7.5% at 2 years and 8.9% at 1 year, respectively) and should be treated when identified. Intervention should be considered for other types of endoleak when associated with aneurysm sac growth larger than 5 mm based on current guidelines. Type II endoleaks are the most common, accounting for 50% of all endoleaks. Up to 90% of type II endoleaks resolve spontaneously or are not associated with sac enlargement, requiring only observation. Although the risk of rupture is less than 1%, cases that require reintervention are challenging. Recurrence is common despite endovascular treatment, and rupture can occur without evidence of sac growth. Type IV endoleaks and endotension are uncommon, are typically benign, and primarily should be observed.

Conclusions and Relevance

Endoleak management depends on the type and presence of sac expansion. Type I and III endoleaks require intervention. Type II endoleaks should be observed and treated selectively in patients with significant sac expansion. Since endoleaks can appear any time after EVAR, at least 1 contrast-enhanced computed tomographic angiogram or duplex ultrasound by an experienced laboratory is recommended every 5 years.

Association of Genetic Polymorphisms and Serum Levels of miR-1-3p with Postoperative Mortality following Abdominal Aortic Aneurysm Repair

BACKGROUND

Several miRNAs have been implicated in the clinical outcomes of cardiovascular disorders, but the role of miR-1-3p in abdominal aortic aneurysm (AAA) prognosis remains unclear. This study aimed to investigate the correlation of single nucleotide polymorphisms (SNPs) in pri-miR-1-3p and mature miR-1-3p expression with postoperative mortality of AAA patients.

METHODS

A total of 230 AAA patients who received AAA repair were recruited and followed up for 5 years. SNP genotyping was carried out using KASP method and relative expression of serum miR-1-3p was measured with qRT-PCR.

RESULTS

Multivariate Cox regression analyses showed that both rs2155975 and rs4591246 variant genotypes were associated with increased all-cause mortality of postoperative AAA patients after adjusting possible confounders. Patients who died tended to have lower baseline miR-1-3p expression (overall and for age < 65 years, aneurysm-related death or cardiac death subgroup) when compared to alive patients; further Cox regression yielded an independent relationship of preoperative low serum miR-1-3p levels with incidents of all-cause death. Patients carrying rs2155975 AG + GG or rs4591246 AG + AA genotype had a higher ratio of low miR-1-3p levels in contrast to those with AA or GG genotype, respectively. The Kaplan-Meier survival curves suggested that the combined genotype in rs2155975 or rs4591246 and low miR-1-3p levels could decrease the overall survival of AAA patients during 5-year follow-up.

CONCLUSIONS

This pilot study demonstrated the importance of rs2155975 and rs4591246 polymorphisms and baseline serum miR-1-3p levels as promising markers to predict mortality among patients following AAA repair.

Successful treatment of a persistent type IA endoleak with endoanchors following chimney endovascular aortic repair

The chimney endovascular aortic repair technique has become an increasingly used option for the treatment of juxtarenal aortic aneurysms; however, type IA and gutter endoleaks complicate this approach in up to 5.9% of cases. Successful treatment of these leaks is challenging. We report a case of a patient who underwent two-vessel chimney endovascular aortic repair in the treatment of a 5.9-cm juxtarenal aortic aneurysm and developed a type IA endoleak. The endoleak was successfully treated with Heli-FX EndoAnchor placement. Resolution of the endoleak was noted at continued follow-up through 54 months.

Sex Differences in Outcomes Following Ruptured Abdominal Aortic Aneurysm Repair

IMPORTANCE

Sex differences in aortic surgery outcomes are commonly reported. However, data on ruptured abdominal aortic aneurysm (rAAA) repair outcomes in women vs men are limited.

OBJECTIVE

To assess differences in perioperative and long-term mortality following rAAA repair in women vs men.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter, retrospective cohort study was conducted using the Vascular Quality Initiative database, which prospectively captures information on patients who undergo vascular surgery across 796 academic and community hospitals in North America. All patients who underwent endovascular or open rAAA repair between January 1, 2003, and December 31, 2019, were included. Outcomes were assessed up to January 1, 2020.

EXPOSURES

Patient sex.

MAIN OUTCOMES AND MEASURES

Demographic, clinical, and procedural characteristics were recorded, and differences between women vs men were assessed using independent t test and χ2 test. The primary outcomes were in-hospital and 8-year mortality. Associations between sex and outcomes were analyzed using univariable and multivariable logistic regression and Cox proportional hazards regression analysis.

RESULTS

A total of 1160 (21.9%) women and 4148 (78.1%) men underwent rAAA repair during the study period. There was a similar proportion of endovascular repairs in women and men (654 [56.4%] vs 2386 [57.5%]). Women were older (mean [SD] age, 75.8 [9.3] vs 71.7 [9.6] years), more likely to have chronic kidney disease (718 [61.9%] vs 2184 [52.7%]), and presented with ruptured aneurysms of smaller diameters (mean [SD] 68 [18.2] vs 78 [30.2] mm). In-hospital mortality was higher in women (34.4% vs 26.6%; odds ratio, 1.44; 95% CI, 1.25-1.66), which persisted after adjusting for demographic, clinical, and procedural characteristics (adjusted odds ratio, 1.36; 95% CI, 1.12-1.66; P = .002). Eight-year survival was lower in women (36.7% vs 49.5%; hazard ratio, 1.25; 95% CI, 1.04-1.50; P = .02), which persisted when stratified by endovascular and open repair. This survival difference existed in both the US and Canada. Variables associated with long-term mortality in women included older age and chronic kidney disease.

CONCLUSIONS AND RELEVANCE

Women who underwent rAAA repair had higher perioperative and 8-year mortality rates following both endovascular and open repair compared with men. Older age and higher rates of chronic kidney disease in women were associated with higher mortality rates. These findings suggest that future studies should assess the reasons for these disparities and whether opportunities exist to improve AAA care for women.