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Reyes Valdivia A, Oikonomou K, Milner R, Kasprzak P, Reijnen MMPJ, Pitoulias G, Torsello GB, Pfister K, de Vries JPPM, Chaudhuri A. The Effect of EndoAnchors on Aneurysm Sac Regression for Patients Treated With Infrarenal Endovascular Repair With Hostile Neck Anatomies: A Propensity Scored Analysis. J Endovasc Ther 2024; 31:438-449. [PMID: 36214450 DOI: 10.1177/15266028221127839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To analyze sac evolution patterns in matched patients with hostile neck anatomy (HNA) treated with standard endovascular aneurysm repair (sEVAR) and endosutured aneurysm repair (ESAR). METHODS Observational retrospective study using prospectively collected data between June 2010 and December 2019. ESAR group data were extracted from the primary arm of the PERU registry with an assigned identifier (NCT04100499) at 8 centers and those from the sEVAR came from 4 centers. Suitability for inclusion required: no proximal endograft adjuncts (besides EndoAnchor use), ≤15 mm neck length and minimum of 12-months follow-up imaging. Bubble-shaped neck (noncylindrical short neck with discontinuous seal) aspect was analyzed. Both groups were analyzed using propensity score matching (PSM) for aortic neck length, width, angulation, and device fixation type. Main outcome assessed was sac evolution patterns (sac expansion and regression were defined as >5mm increase or decrease, of the maximum sac diameter respectively; all AAAs within this ±5 mm range in diameter change were considered stable) and secondary outcomes were type-Ia endoleaks; other endoleaks and mortality. A power analysis calculation >80% was confirmed for sac regression evaluation. RESULTS After exclusions, PSM resulted in 96 ESAR and 96 sEVAR patients. Mean imaging follow-up (months) was 44.4±21.3 versus 43.0±19.6 (p=0.643), respectively. The overall number of patients achieving sac regression was higher in the ESAR group (n=57, 59.4% vs n=31, 32.3%; p<0.001) and the cumulative sac regression achieved at 5 years was 65% versus 38% (p=0.003) in favor of the ESAR group. There were no statistically significant differences in type-Ia endoleak and/or other endoleaks. Univariate analysis for sac regression patients in the sEVAR and ESAR group individually showed the bubble-shape neck as a predictor of sac regression failure. There were no statistical differences in overall and aneurysm-related mortality. CONCLUSION Endosutured aneurysm repair provided improved rates of sac regression for patients with AAA and HNA when compared with sEVAR at midterm and up to 5 years, despite similar rates of type-Ia endoleaks, and the need to consider some important limitations. The presence of bubble-shaped neck was a predictor of sac regression failure for both groups equally. CLINICAL IMPACT The use of EndoAnchors aids and improves EVAR treatment in hostile neck anatomies by an increased rate of sac regression when compared to EVAR treatment alone in up to 5 year analysis. Moreover, a trend to reduced number of type Ia endoleaks is also achieved, although not significant in the present study. This data, adds to current and growing evidence on the usefulness of EndoAnchors for AAA endovascular treatment.
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Affiliation(s)
- Andrés Reyes Valdivia
- Department of Vascular and Endovascular Surgery, Ramón y Cajal's University Hospital, Madrid, Spain
| | - Kyriakos Oikonomou
- Department of Vascular Surgery, University Medical Centre Regensburg, Regensburg, Germany
- Department of Vascular and Endovascular Surgery, Cardiovascular Surgery Clinic, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Ross Milner
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Piotr Kasprzak
- Department of Vascular Surgery, University Medical Centre Regensburg, Regensburg, Germany
| | - Michel M P J Reijnen
- Department of Surgery, Rijnstate, Arnhem, The Netherlands
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Georgios Pitoulias
- Division of Vascular Surgery, 2nd Department of Surgery, Faculty of Medicine, "G. Gennimatas" Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Karin Pfister
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Jean-Paul P M de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Arindam Chaudhuri
- Bedfordshire-Milton Keynes Vascular Center, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
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Reyes Valdivia A, Oikonomou K, Milner R, Pitoulias A, Reijnen MMPJ, Pfister K, Tinelli G, Csobay-Novák C, Pratesi G, Ferreira LM, de Vries JPPM, Chaudhuri A. Endosutured aneurysm repair (ESAR) of abdominal aortic aneurysms with short necks achieves acceptable mid-term outcomes - results from the PERU registry. Ann Vasc Surg 2024:S0890-5096(24)00118-3. [PMID: 38579908 DOI: 10.1016/j.avsg.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/31/2023] [Accepted: 01/02/2024] [Indexed: 04/07/2024]
Abstract
INTRODUCTION The study aims to describe midterm outcomes following treatment of infrarenal abdominal aortic aneurysms (AAAs) with short necks by endosutured aneurysm repair (ESAR) using the Heli-FX EndoAnchor system. METHODS This is a retrospective study of prospectively collected data from nine vascular surgery departments between June 2010 - December 2019, including treated AAAs with neck lengths ≤ 10mm. The decision for the use of EndoAnchors was made by the treating surgeon or multidisciplinary aortic committee according to each centre's practice. There were two subgroups further assessed according to neck length, A (≥4 and < 7mm) and B (≥7 and ≤10mm). The main outcomes analysed were technical success, freedom from type Ia endoleaks (TIaEL), sac size increase, all-cause (ACM) and aneurysm related mortality (ARM). RESULTS 76 patients were included in the study, 17 fell into Subgroup A and 59 into subgroup B. Median follow-up for the cohort was 40.5 (IQR 12-61) months. A median of 6 (IQR 3) EndoAnchors were deployed in each subject. Technical success was 86.8% for the total group, 82.4% and 88.1% (p=0.534) for subgroups A and B respectively. Six out of ten (60%) of TIaELs at the completion angiographies showed spontaneous resolution. Cumulative freedom from TIaEL at 3 and 5 years for the total group was 89% and 84% respectively; this was 93% and 74% for subgroup A and 88% at both intervals in subgroup B (p=0.545). In total, there were 7 (9.2%) patients presenting with type Ia endoleaks over the entire study period. Two (11.8%) in subgroup A and 5 (8.5%) in subgroup B (p=0.679). There were more patients with sac regression in subgroup B (subgroup A=6 - 35.3% versus subgroup B=34 - 57.6%, p=0.230) with no statistical significance. ACM was 19 (25%) patients, with no difference (4 - 23.5% versus 15 - 25.4%, p=0.874) between subgroups; whereas ARM occurred in one patient from subgroup A and 3 from subgroup B. CONCLUSIONS This study demonstrates reasonable outcomes for patients with short-necked AAAs treated by ESAR in terms of type Ia endoleaks up to 5 year follow up. EndoAnchor use should be judiciously evaluated in short necks and may be a reasonable option when anatomical constraints are encountered, mainly for those with 7-10mm neck lengths. Shorter neck length aspects, as indicated by the results from Group A, may be an alternative when no other options are available or feasible.
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Affiliation(s)
- Andrés Reyes Valdivia
- Department of Vascular and Endovascular Surgery. Ramón y Cajal´s University Hospital, Madrid, Spain.
| | - Kyriakos Oikonomou
- Department of Vascular and Endovascular Surgery, Cardiovascular Surgery Clinic, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt.
| | - Ross Milner
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago Medicine, Chicago, Ill.
| | - Apostolos Pitoulias
- Department of Vascular and Endovascular Surgery, Research Vascular Center, Asklepios Clinic Langen, Langen, Germany.
| | - Michel M P J Reijnen
- Department of Surgery, Rijnstate, Arnhem and the Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, The Netherlands.
| | - Karin Pfister
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany.
| | - Giovanni Tinelli
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Csaba Csobay-Novák
- Semmelweis Aortic Center, Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
| | - Giovanni Pratesi
- a)Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, b)IRCCS Ospedale Policlinico San Martino, Genoa.
| | | | - Jean-Paul P M de Vries
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, and Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, Groningen, The Netherlands.
| | - Arindam Chaudhuri
- Bedfordshire - Milton Keynes Vascular Centre, Bedfordshire Hospitals Foundation Trust, Bedford, UK.
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Vos CG, Fouad F, Dieleman IM, Schuurmann RC, de Vries JPP. Importance of sac regression after EVAR and the role of EndoAnchors. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:99-105. [PMID: 38551514 DOI: 10.23736/s0021-9509.24.12992-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
The initial success and widespread adoption of endovascular aneurysm repair (EVAR) for the treatment of abdominal aortic aneurysms have been tempered by numerous reports of secondary interventions and increased long-term mortality compared with open repair. Over the past decade, several studies on postoperative sac dynamics after EVAR have suggested that the presence of sac regression is a benign feature with a favorable prognosis. Conversely, increasing sacs and even stable sacs can be indicators of more unstable sac behavior with worse outcomes in the long-term. Endoleaks were initially perceived as the main drivers of sac behavior. However, the observation that sac regression can occur in the presence of endoleaks, and vice versa - increasing sacs without evidence of endoleak - on imaging studies, suggests the involvement of other contributing factors. These factors can be divided into anatomical factors, patient characteristics, sac thrombus composition, and device-related factors. The shift of interest away from especially type 2 endoleaks is further supported by promising results with the use of EndoAnchors regarding postoperative sac behavior. This review provides an overview of the existing literature on the implications and known risk factors of post-EVAR sac behavior, describes the accurate measurement of sac behavior, and discusses the use of EndoAnchors to promote sac regression.
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Affiliation(s)
- Cornelis G Vos
- Department of Surgery, Martini Hospital, Groningen, the Netherlands
| | - Fatima Fouad
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands -
| | - Isabel M Dieleman
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Richte Cl Schuurmann
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Jean-Paul Pm de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
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Orimoto Y, Ishibashi H, Arima T, Imaeda Y, Maruyama Y, Mitsuoka H, Kodama A. Long-Term Outcomes of Simple Endovascular Aneurysm Repair Based on the Initial Aortic Diameter. Ann Thorac Cardiovasc Surg 2024; 30:23-00098. [PMID: 37880083 PMCID: PMC10902653 DOI: 10.5761/atcs.oa.23-00098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/10/2023] [Indexed: 10/27/2023] Open
Abstract
PURPOSE We aimed to investigate the effects of initial abdominal aortic aneurysm (AAA) diameter on aneurysmal sac expansion/shrinkage, endoleaks, and reintervention postelective simple endovascular aneurysm repair (EVAR). METHODS Overall, 228 patients monitored for >1 year after EVAR were analyzed. Male and female participants with initial AAA diameters <55 mm and <50 mm, respectively, composed the small group (group S), while those with initial AAA diameters ≥55 mm (men) and ≥50 mm (women) composed the large group (group L). Aneurysmal sac expansion of 10 mm and/or reintervention during follow-up (composite event) and its related factors were evaluated. RESULTS The 5-year freedom from composite event rate was significantly higher in group S (92.4 ± 2.8%) than that in group L (79.1 ± 4.9%; P <0.01). Multivariate analysis revealed AAA diameters before EVAR in group S (hazard ratio, 0.38; 95% confidence interval, 0.18-0.81; P = 0.01) and type II endoleak (T2EL) at discharge (hazard ratio, 2.83; 95% confidence interval, 1.29-6.20; P <0.01) as factors associated with the composite event. The freedom from composite event rate decreased to 51 ± 13% at 5 years in group L with T2EL. CONCLUSIONS Group S had high freedom from composite event rate; in group L, the rate decreased to 51% at 5 years with T2EL at discharge.
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Affiliation(s)
- Yuki Orimoto
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hiroyuki Ishibashi
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takahiro Arima
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Yusuke Imaeda
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Yuki Maruyama
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hiroki Mitsuoka
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Akio Kodama
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
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Wegner M, Fontaine V, Nana P, Dieffenbach BV, Fabre D, Haulon S. Artificial Intelligence-Assisted Sac Diameter Assessment for Complex Endovascular Aortic Repair. J Endovasc Ther 2023:15266028231208159. [PMID: 37902445 DOI: 10.1177/15266028231208159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
PURPOSE Artificial intelligence (AI) using an automated, deep learning-based method, Augmented Radiology for Vascular Aneurysm (ARVA), has been verified as a viable aide in aneurysm morphology assessment. The aim of this study was to evaluate the accuracy of ARVA when analyzing preoperative and postoperative computed tomography angiography (CTA) in patients managed with fenestrated endovascular repair (FEVAR) for complex aortic aneurysms (cAAs). MATERIALS AND METHODS Preoperative and postoperative CTAs from 50 patients (n=100 CTAs) who underwent FEVAR for cAAs were extracted from the picture archiving and communication system (PACS) of a single aortic center equipped with ARVA. All studies underwent automated AI aneurysm morphology assessment by ARVA. Appropriate identification of the outer wall of the aorta was verified by manual review of the AI-generated overlays for each patient. Maximum outer-wall aortic diameters were measured by 2 clinicians using multiplanar reconstruction (MPR) and curved planar reformatting (CPR), and among studies where the aortic wall was appropriately identified by ARVA, they were compared with ARVA automated measurements. RESULTS Identification of the outer wall of the aorta was accurate in 89% of CTA studies. Among these, diameter measurements by ARVA were comparable to clinician measurements by MPR or CPR, with a median absolute difference of 2.4 mm on the preoperative CTAs and 1.6 mm on the postoperative CTAs. Of note, no significant difference was detected between clinician measurements using MPR or CPR on preoperative and postoperative scans (range 0.5-0.9 mm). CONCLUSION For patients with cAAs managed with FEVAR, ARVA provides accurate preoperative and postoperative assessment of aortic diameter in 89% of studies. This technology may provide an opportunity to automate cAA morphology assessment in most cases where time-intensive, manual clinician measurements are currently required. CLINICAL IMPACT In this retrospective analysis of preoperative and postoperative imaging from 50 patients managed with FEVAR, AI provided accurate aortic diameter measurements in 89% of the CTAs reviewed, despite the complexity of the aortic anatomies, and in post-operative CTAs despite metal artifact from stent grafts, markers and embolization materials. Outliers with imprecise automated aortic overlays were easily identified by scrolling through the axial AI-generated segmentation MPR cuts of the entire aorta.This study supports the notion that such emerging AI technologies can improve efficiency of routine clinician workflows while maintaining excellent measurement accuracy when analyzing complex aortic anatomies by CTA.
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Affiliation(s)
- Moritz Wegner
- Department of Vascular and Endovascular Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Vincent Fontaine
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Petroula Nana
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Bryan V Dieffenbach
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris-Saclay University, Le Plessis-Robinson, France
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Spinella G, Fantazzini A, Finotello A, Vincenzi E, Boschetti GA, Brutti F, Magliocco M, Pane B, Basso C, Conti M. Artificial Intelligence Application to Screen Abdominal Aortic Aneurysm Using Computed tomography Angiography. J Digit Imaging 2023; 36:2125-2137. [PMID: 37407843 PMCID: PMC10501994 DOI: 10.1007/s10278-023-00866-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/13/2023] [Accepted: 06/06/2023] [Indexed: 07/07/2023] Open
Abstract
The aim of our study is to validate a totally automated deep learning (DL)-based segmentation pipeline to screen abdominal aortic aneurysms (AAA) in computed tomography angiography (CTA) scans. We retrospectively evaluated 73 thoraco-abdominal CTAs (48 AAA and 25 control CTA) by means of a DL-based segmentation pipeline built on a 2.5D convolutional neural network (CNN) architecture to segment lumen and thrombus of the aorta. The maximum aortic diameter of the abdominal tract was compared using a threshold value (30 mm). Blinded manual measurements from a radiologist were done in order to create a true comparison. The screening pipeline was tested on 48 patients with aneurysm and 25 without aneurysm. The average diameter manually measured was 51.1 ± 14.4 mm for patients with aneurysms and 21.7 ± 3.6 mm for patients without aneurysms. The pipeline correctly classified 47 AAA out of 48 and 24 control patients out of 25 with 97% accuracy, 98% sensitivity, and 96% specificity. The automated pipeline of aneurysm measurements in the abdominal tract reported a median error with regard to the maximum abdominal diameter measurement of 1.3 mm. Our approach allowed for the maximum diameter of 51.2 ± 14.3 mm in patients with aneurysm and 22.0 ± 4.0 mm in patients without an aneurysm. The DL-based screening for AAA is a feasible and accurate method, calling for further validation using a larger pool of diagnostic images towards its clinical use.
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Affiliation(s)
- Giovanni Spinella
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Viale Benedetto XV 6, 16132, Genoa, Italy.
- Vascular and Endovascular Surgery Clinic, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy.
| | | | | | - Elena Vincenzi
- Camelot Biomedical System, Genoa, Italy
- Department of Computer Science, Robotics and Systems Engineering, University of Genoa, BioengineeringGenoa, Italy
| | | | | | - Marco Magliocco
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Bianca Pane
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Viale Benedetto XV 6, 16132, Genoa, Italy
- Vascular and Endovascular Surgery Clinic, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy
| | | | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
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Yamamoto T, Tsukube T, Wada Y, Hoshino M, Yagi N, Nakagawa K, Nakashima Y, Okada K, Seto T. Mechanism of sac expansion without evident endoleak analyzed with X ray phase-contrast tomography. JVS Vasc Sci 2023; 4:100123. [PMID: 37662587 PMCID: PMC10474490 DOI: 10.1016/j.jvssci.2023.100123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 07/09/2023] [Indexed: 09/05/2023] Open
Abstract
Objective Synchrotron radiation-based X ray phase-contrast tomography (XPCT) was used in this study to evaluate abdominal aorta specimens from patients with sac expansion without evidence of an endoleak (endotension) following endovascular aortic repair (EVAR) for an abdominal aortic aneurysm (AAA). The aim of this study was to analyze the morphologic structure of the aortic wall in patients with this condition and to establish the cause of the endotension. Methods Human aortic specimens of the abdominal aorta were obtained during open repair, fixed with formalin, and analyzed among three groups. Group A was specimens from open abdominal aortic aneurysm repairs (n = 7). Group E was specimens from sac expansion without an evident endoleak after EVAR (n = 7). Group N was specimens from non-aneurysmal "normal" cadaveric abdominal aortas (n = 5). Using XPCT (effective voxel size, 12.5 μm; density resolution, 1 mg/cm3), we measured the density of the tunica media (TM) in six regions of each sample. Then, any changes to the elastic lamina and the vasa vasorum were analyzed pathologically. The specimens were immunohistochemically examined with anti-CD31 and vascular endothelial growth factor antibodies. Results The time from EVAR to open aortic repair was 64.2 ± 7.2 months. There were significant differences in the thickness of the TM among three groups: 0.98 ± 0.03 mm in Group N; 0.31 ± 0.01 mm in Group A; and 0.15 ± 0.03 mm in Group E (P < .005). There were significant differences in the TM density among the groups: 1.087 ± 0.004 g/cm3 in Group N; 1.070 ± 0.001 g/cm3 in Group A; and 1.062 ± 0.007 g/cm3 in Group E (P < .005). Differences in the thickness and density of the TM correlated with the thickness of the elastic lamina; in Group N, uniform high-density elastic fibers were observed in the TM. By contrast, a thinning of the elastic lamina in the TM was observed in Group A. A marked thinness and loss of elastic fibers was observed in Group E. CD31 immunostaining revealed that the vasa vasorum was localized in the adventitia and inside the outer third of the TM in Group N, and in the middle of the TM in Group A. In Group E, the vasa vasorum advanced up to the intima with vascular endothelial growth factor-positive cells in the intimal section. Conclusions XPCT could be used to demonstrate the densitometric property of the aortic aneurysmal wall after EVAR. We confirmed that the deformation process that occurs in the sac expansion after EVAR without evidence of an endoleak could be explained by hypoxia in the aortic wall.
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Affiliation(s)
- Takateru Yamamoto
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Takuro Tsukube
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital, Kobe, Japan
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuko Wada
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Masato Hoshino
- Research and Utilization Division, Japan Synchrotron Radiation Research Institute / SPring-8, Sayo, Hyogo, Japan
| | - Naoto Yagi
- Research and Utilization Division, Japan Synchrotron Radiation Research Institute / SPring-8, Sayo, Hyogo, Japan
| | - Kazunori Nakagawa
- Department of Pathophysiological and Experimental Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yutaka Nakashima
- Department of Pathology, Kyushu University Hospital, Fukuoka, Japan
| | - Kenji Okada
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tatsuichiro Seto
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Nagano, Japan
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Mezzetto L, D’Oria M, Lepidi S, Mastrorilli D, Calvagna C, Bassini S, Taglialavoro J, Bruno S, Veraldi GF. A Scoping Review on the Incidence, Risk Factors, and Outcomes of Proximal Neck Dilatation after Standard and Complex Endovascular Repair for Abdominal Aortic Aneurysms. J Clin Med 2023; 12:jcm12062324. [PMID: 36983324 PMCID: PMC10054682 DOI: 10.3390/jcm12062324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/20/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
Background: To define proximal neck dilation (PND) after standard endovascular aneurysm repair (EVAR) and fenestrated EVAR (FEVAR), determining: incidence and risk factors; evidence base that links PND to outcomes of patients; recurring themes or gaps in the literature. Methods: We performed a scoping review and included only full-text English articles with follow-up focusing on PND in patients undergoing EVAR or FEVAR, published between 2000 and 2022. The following PICO question was used to build the search equation: in patients with abdominal-aortic-aneurysm (AAA) (Population) undergoing endovascular repair (Intervention), what are the incidence, risk factors and prognosis of radiologically defined PND (Comparison) on short-term and long-term outcomes (Outcomes)? Results: 15 articles were included after review. Measurement protocols for proximal aortic neck (PAN) varied among individual studies and the definition of PND resulted as heterogeneous. Rate of patients with a PND ranged between 0% and 41%. Large proximal neck (>28 mm) and excessive graft sizing (30%) were predictors for PND. New endografts with low outward radial forces and FEVAR seemed to be protective. Surgical conversion was the definitive option in the case of patients unfit for other endovascular treatments. Conclusions: PND is a frequent finding after EVAR and FEVAR. Excessive graft oversizing and large baseline PAN were predictors of neck enlargement, independently by the type of standard endograft used. FEVAR may be considered protective against complications, together with endografts using low outward radial forces. Lifelong radiological follow-up is mandatory.
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Affiliation(s)
- Luca Mezzetto
- Unit of Vascular Surgery, Integrated University Hospital and Trust of Verona, Piazzale A. Stefani 1, 37124 Verona, Italy
- Correspondence: ; Tel.: +39-045-812-2505
| | - Mario D’Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, 34129 Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, 34129 Trieste, Italy
| | - Davide Mastrorilli
- Unit of Vascular Surgery, Integrated University Hospital and Trust of Verona, Piazzale A. Stefani 1, 37124 Verona, Italy
| | - Cristiano Calvagna
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, 34129 Trieste, Italy
| | - Silvia Bassini
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, 34129 Trieste, Italy
| | - Jacopo Taglialavoro
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, 34129 Trieste, Italy
| | - Salvatore Bruno
- Unit of Vascular Surgery, Integrated University Hospital and Trust of Verona, Piazzale A. Stefani 1, 37124 Verona, Italy
| | - Gian Franco Veraldi
- Unit of Vascular Surgery, Integrated University Hospital and Trust of Verona, Piazzale A. Stefani 1, 37124 Verona, Italy
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Shen Y, Wang J, Zhao J, Yuan D, Wang T, Huang B. DANCER: Study protocol of a prospective, non-randomized controlled trial for crossed limb versus standard limb configuration in endovascular abdominal aortic aneurysm repair. Front Cardiovasc Med 2022; 9:1046200. [DOI: 10.3389/fcvm.2022.1046200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/27/2022] [Indexed: 11/10/2022] Open
Abstract
BackgroundHostile anatomy, especially severely angulated neck and tortuous iliac arteries, has always been a conundrum in endovascular aneurysm repair (EVAR). Crossed limb (CL) graft, also called the “ballerina technique,” has been utilized to address this problem by facilitating gate cannulation. In terms of short and long-term outcomes, correlated studies have made inconsistent conclusions and this issue remains controversial. Based on a previous cohort study conducted in our center, we aim to prospectively compare the safety and efficacy between CL and standard limb (SL) configuration in patients receiving EVAR.MethodsThis is a prospective, single-center, non-randomized controlled trial. A total of 275 patients who meet the inclusion criteria will be enrolled and allocated with a 4:11 ratio of CL to SL, which is based on results of our previous study. All patients will receive same perioperative management and postoperative medications. All EVAR procedures will be performed under standard protocol, utilizing Endurant II or IIs Stent Graft. The configuration of the graft stent will be decided by surgeons and confirmed by final angiography. The primary outcome is 3-year freedom from major adverse limb-graft events (MALEs). Endpoints will be assessed at the following time points: 1, 6, 12, 24, and 36 months.DiscussionTo our best knowledge, this crosseD vs. stANdard Configuration in Endovascular Repair (DANCER) trial is the first non-randomized controlled trial to compare these two graft configurations in EVAR. The main aim is to compare the MALEs between two groups at 3 years postoperatively. This trial will hopefully provide high-level evidence for employing CL in EVAR.Clinical trial registration[www.chictr.org.cn], identifier [ChiCTR2100053055].
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Infrarenal Remains Infrarenal-EVAR Suitability of Small AAA Is Rarely Compromised despite Morphological Changes during Surveillance. J Clin Med 2022; 11:jcm11185319. [PMID: 36142966 PMCID: PMC9501454 DOI: 10.3390/jcm11185319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/02/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
The aim was to analyze small abdominal aortic aneurysm (AAA) morphology during surveillance with regard to standard endovascular aortic repair (EVAR) suitability. This retrospective single-center study included all patients (n = 52, 48 male, 70 ± 8 years) with asymptomatic AAA ≤ 5.4 cm undergoing ≥2 computed tomography angiography(CTA)/magnetic resonance imaging (MRI) studies (interval: ≥6 months) between 2010 and 2018. Aneurysm diameter, neck quality (shape, length, angulation, thrombus/calcification), aneurysm thrombus, and distal landing zone diameters were compared between first and last CTA/MRI. Resulting treatment plan changes were determined. Neck shortening occurred in 25 AAA (mean rate: 2.0 ± 4.2 mm/year). Neck thrombus, present in 31 patients initially, increased in 16. Average AAA diameters were 47.7 ± 9.3 mm and 56.3 ± 11.6 mm on first and last CTA/MRI, mean aneurysm growth rate was 4.2 mm/year. Aneurysm thrombus was present in 46 patients primarily, increasing in 32. Neck thrombus growth and neck length change, aneurysm thrombus amount and aneurysm growth and aneurysm growth and neck angulation were significantly correlated. A total of 46 (88%) patients underwent open (12/46) or endovascular (34/46) surgery. The planned procedure changed from EVAR to fenestrated EVAR in two patients and from double to triple fenestrated EVAR in one. Thus, standard EVAR suitability was predominantly maintained as the threshold diameter for surgery was reached despite morphological changes. Consecutively, a possibly different pathogenesis of infra- versus suprarenal AAA merits further investigation.
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van Rijswijk RE, Groot Jebbink E, Holewijn S, Stoop N, van Sterkenburg SM, Reijnen MMPJ. Predictors of Abdominal Aortic Aneurysm Shrinkage after Endovascular Repair. J Clin Med 2022; 11:jcm11051394. [PMID: 35268486 PMCID: PMC8910935 DOI: 10.3390/jcm11051394] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 02/01/2023] Open
Abstract
Recent studies demonstrate that patients with a shrinking abdominal aortic aneurysm (AAA), one-year after endovascular repair (EVAR), have better long-term outcomes than patients with a stable AAA. It is not known what factors determine whether an AAA will shrink or not. In this study, a range of parameters was investigated to identify their use in differentiating patients that will develop a shrinking AAA from those with a stable AAA one-year after EVAR. Hundred-seventy-four patients (67 shrinking AAA, 107 stable AAA) who underwent elective, infrarenal EVAR were enrolled between 2011-2018. Long-term survival was significantly better in patients with a shrinking AAA, compared to those with a stable AAA (p = 0.038). Larger preoperative maximum AAA diameter was associated with an increased likelihood of developing AAA shrinkage one-year after EVAR-whereas older age and larger preoperative infrarenal β angle were associated with a reduced likelihood of AAA shrinkage. However, this multivariate logistic regression model was only able to correctly identify 66.7% of patients with AAA shrinkage from the total cohort. This is not sufficient for implementation in clinical care, and therefore future research is recommended to dive deeper into AAA anatomy, and explore potential predictors using artificial intelligence and radiomics.
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Affiliation(s)
- Rianne E. van Rijswijk
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, 7522 NH Enschede, The Netherlands
- Correspondence:
| | - Erik Groot Jebbink
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, 7522 NH Enschede, The Netherlands
| | - Suzanne Holewijn
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
| | - Nicky Stoop
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
| | - Steven M. van Sterkenburg
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
| | - Michel M. P. J. Reijnen
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, 7522 NH Enschede, The Netherlands
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