The Association between Device Instructions for Use Adherence and Outcomes after Elective Endovascular Aortic Abdominal Aneurysm Repair

Improved Endovascular Aortic Repair Durability in Patients Achieving Increased Shortest Apposition Length: A Multi-Centre Analysis

OBJECTIVE

Endovascular aortic repair (EVAR) for an aneurysm of the abdominal aorta (AAA) is associated with long-term complications, such as endoleaks, resulting in a significant re-intervention rate. This study investigates the prognostic value of (change of) proximal seal length on post-EVAR computed tomography angiography (CTA) for predicting type 1a endoleak. It further proposes a risk-stratified imaging follow-up algorithm.

DESIGN

Multicentre, retrospective, observational study of consecutive patients who underwent elective EVAR for infrarenal AAA between 2015 and 2018 at 3 high-volume hospitals in the Netherlands.

MATERIALS AND METHODS

Aorta morphology and endograft position analysis was performed. Shortest apposition length (SAL) was measured on the first post-EVAR CTA and, if available, on the last CTA. Change of SAL through time was categorized as increasing, stable, or decreasing and correlated with type 1a endoleak and secondary interventions for endoleak. Kaplan-Meier analysis was used to calculate type 1a endoleak free and re-intervention-free survival.

RESULTS

Three hundred ten AAA patients with a median follow-up of 51 (Q1, 17; Q3, 71) months were included. A median SAL of 22.8 mm (Q1, 15.9; Q1, 30.4) was measured on the first post-EVAR CTA. In 168 of 310 patients (54%), a second post-EVAR CTA was available, in which 71 (42%) showed increasing SAL over time. No type 1a endoleak developed in the increasing SAL group, whereas 1 of 43 (2%) in the stable group and 10 of 54 (19%) in the decreasing group developed type 1a endoleak. Five years post-EVAR, type 1a endoleak-free survival was 100% in the increasing SAL group versus 97.1% in the stable SAL group (p=0.195), and 81.6% in the decreasing SAL group (p<0.001). The re-intervention for all types of endoleak-free survival was 100% in the increasing SAL group versus 84.6% in the stable SAL group (p<0.001), and 60.7% (p<0.001) in the decreasing SAL group.

CONCLUSION

Increasing SAL after EVAR for infrarenal degenerative AAA is an indicator of durable success without type 1a endoleak and endoleak-associated secondary intervention within 5 years. Decreasing SAL is associated with development of type 1a endoleak after EVAR. Evaluation of (change of) the proximal seal could be a valuable part of follow-up after EVAR.Clinical ImpactEvaluation of proximal seal length after endovascular aortic repair offers valuable prognostic information regarding the risk of type 1a endoleak. Implementation could refine current follow-up algorithms to better stratify patients who have a substantial risk of type Ia endoleak from patients who may benefit from limited image surveillance.

Endovascular Aneurysm Repair with Zenith Alpha Abdominal Stent-Graft in Hostile and Nonhostile Aortic Neck Anatomies

BACKGROUND

The aim of this study was to evaluate early and 5-year outcomes of endovascular aneurysm repair (EVAR) with Zenith Alpha Abdominal in the context of a multicenter regional retrospective registry comparing patients with hostile and nonhostile aortic necks.

METHODS

A retrospectively maintained dataset identified all consecutive patients with Abdominal Aortic Aneurysms underwent elective EVAR with implantation of a Zenith Alpha Abdominal in 7 centers between January 2016 and December 2022. Two-hundred-twenty-eight patients have been included in the present study: 98 (43%) with a hostile neck (Group HN), and 130 (57%) with a no-hostile neck (Group n-HN). Early (30-day) outcomes in terms of technical and clinical successes were assessed and compared. Estimated 5-year outcomes were evaluated and compared in terms of survival, freedom from type I/III endoleak, freedom from surgical conversion, freedom from limb graft occlusion, and freedom from any device-related reintervention(s) by using life-table analysis (Kaplan-Meier curves) and log-rank test.

RESULTS

Female gender was more frequent in Group HN (15.3% vs. 5.3%, P = 0.01). Thirty-day technical success rate was 96.9% in Group HN, and 100% in Group n-HN (P = 0.08), while 30-day clinical success rate was 96.9% in Group HN, and 99.2% in Group n-HN (P = 0.21). Overall median follow-up period was 32.1 months [InterQuartile Range 14-47]. Estimated 5-year survival rates were comparable (67.1% in Group HN, and 77.9% in Group n-HN, P = 0.47). During the follow-up no endoleak type III have been detected in both groups. At 5 years there were no differences between the two groups in terms of freedom from surgical conversion (95.1% Group HN vs. 96.7% Group n-HN; P = 0.71, log-rank 0.14), freedom from limb graft occlusion (95.7% Group HN vs. 93.5% Group n-HN; P = 0.58, log-rank 0.29), and freedom from any device-related reintervention(s) (70.5% Group HN vs. 89.7% Group n-HN; P = 0.19, log-rank 1.72). Starting from the third year of follow-up, hostile neck affected type I endoleak rate (70.2% Group HN vs. 98.4% Group n-HN; P = 0.008, log-rank 6.96). Female gender was the only factor affecting type I endoleak onset during the follow-up (P = 0.02; log-rank = 5.44).

CONCLUSION

In the present multicenter experience hostile neck was more frequent in female patients. Hostile neck affected type I endoleak rates in patients undergoing Zenith Alpha Abdominal implantation starting from the third year of follow-up from the index procedure.

Type IA Endoleak Correction With Fenestrated Devices After EVAR: Outcomes and Predictors of Secondary Failure

PURPOSE

The aim of this study was to review the results of fenestrated stent-graft (Fenestrated Endovascular Aortic Repair [FEVAR]) implantation to treat patients with type IA endoleaks after prior infrarenal endovascular aortic repair (EVAR).

METHODS

A retrospective single-center analysis of prospectively collected data was conducted, including consecutive patients who underwent FEVAR to correct a type IA endoleak between November 2009 and April 2021. All devices were manufactured by Cook Medical (INC, Bloomington, Indiana). Demographic details, anatomical features, fenestrated stent-graft configuration, technical success, and major adverse events (MAEs) were recorded according to current SVS standards. The primary endpoint was freedom-from-significant aneurysm sac expansion (≥5 mm) and survival according to the Kaplan-Meier analysis. Secondary endpoints included 30-day outcomes, freedom-from-all-cause mortality, and aortic-related secondary interventions. Multivariate Cox regression was performed to identify factors associated with the study endpoints.

RESULTS

Overall, 47 patients (89% male, median age 80) were included. Median time from initial EVAR was 60 months [41-72]. Median pre-FEVAR maximal aneurysm diameter was 68mm [62-79]. Median fluoroscopy time and dose area product were, respectively, 49 min [36-63] and 66 Gy.cm2 [38-101]. Technical success rate was 96% with no 30-day deaths reported. Two (4.3%) renal MAE occurred. Median follow-up was 22 months [12-36]. Two-year freedom-from-aneurysm sac expansion and aortic-related secondary intervention were 80% [66-96] and 69% [55-87], respectively. From the multivariate analysis, the configuration of the fenestrated device was not predictive of aneurysm sac expansion, whereas only the preoperative aneurysm maximal diameter was an independent predictor (hazard ratio [HR] [per 1 mm increment]=1.05 [1.01-1.10]; p=0.016) and was associated with a higher risk of aortic-related secondary intervention (HR [per 1 mm increment]=1.07 [1.02-1.12]; p=0.006). Other predictors of aortic-related secondary intervention were pre-existing type IB or III endoleak (HR=7.89 [1.39-44.8]; p=0.020) and aortic degeneration above the primary EVAR (HR=16.6 [1.88-147], p=0.011).

CONCLUSION

Late type IA endoleak after EVAR can be treated safely with a fenestrated stent-graft; preoperative maximum aneurysm diameter is associated with an increased risk of later aneurysm sac growth. Close follow-up is mandatory in this subgroup of patients given the high reintervention rate.

CLINICAL IMPACT

Type IA endoleak following endovascular aneurysm repair (EVAR) can be treated using a fenestrated stent-graft (FEVAR). Treatment options include the addition of a fenestrated cuff alone or complete relining of the previous graft with either a 3-component device or a unibody bifurcated FEVAR. Regardless of the device configuration the treatment appears to be safe but remains associated with high rates of reintervention and aneurysm growth. Although no significant differences have been observed in long-term outcomes, a complete relining with a bifurcated FEVAR may be preferred as a first-line approach, as it offers the advantage of addressing occult associated Type III endoleaks and reducing the risk of component disconnection.

Fenestrated and Branched Endovascular Aortic Repair and Mortality at Hospitals Without Investigational Device Trials

Importance

Fenestrated and branched endovascular aortic repairs (F/BEVAR) have been adopted by many centers. However, national trends of F/BEVAR use remain unclear, particularly at sites who perform them without an US Food and Drug Adminstration (FDA)-approved investigational device exemption (IDE).

Objective

To quantify the use of F/BEVAR in the US and to determine if mortality was different at IDE vs non-IDE sites.

Design, Setting, and Participants

This retrospective cohort study examined 100% fee-for-service Medicare claims data from 2016 to 2023. Participants were patients who underwent endovascular treatment of the visceral aorta incorporating 2 or more visceral artery endoprostheses. Hospitals with vs without an IDE were identified using hospitals' Employer Identification Number as a time varying exposure.

Exposure

F/BEVAR.

Main Outcomes and Measures

Trends in the center-level F/BEVAR case volume stratified by IDE status were assessed using cumulative incidence curves. Mortality outcomes at 30 days and 3 years were compared using Kaplan-Meier methods and Cox proportional hazards models with adjustment for baseline patient characteristics.

Results

From 2016 to 2023, 8017 patients were treated with F/BEVAR at 549 hospitals. The median (IQR) age was 75.8 (71.3-80.8) years; 5795 patients (72.3%) were male and 2222 (27.7%) female. A total of 2226 F/BEVAR (27.8%) were performed at 22 hospitals with an IDE. The number of patients treated with F/BEVAR increased from 771 in 2016 to 1251 in 2023. The median (IQR) annual case volume per hospital was significantly higher at IDE sites (22.3 [11.0-30.4] vs 1.2 [1.0-2.0] cases/y; P < .001); 18 IDE sites (90.0%) and 20 non-IDE sites (3.7%) completed 9 or more cases per year. The 30-day mortality (3.0% vs 4.9%) but not 3-year mortality (26.0% vs 27.1%) was lower for patients treated at hospitals with vs without an IDE. After risk adjustment, both 30-day (odds ratio, 0.47; 95% CI, 0.32-0.69) and midterm mortality (hazard ratio, 0.81; 95% CI, 0.69-0.95) were lower for patients treated at IDE sites.

Conclusions and Relevance

The use of F/BEVAR is increasing across the United States, with the majority of cases being performed outside of IDE studies and at low-volume centers. F/BEVAR performed at non-IDE centers are associated with higher adjusted 30-day and midterm mortality. Transparent outcome reporting and identification of process measures from IDE sites may help achieve more equity in patient outcomes.

Geometric Analysis of the Gore Excluder Conformable Endoprosthesis in the Infrarenal Aortic Neck: One Year Results of the EXCeL Registry

OBJECTIVE

The Gore Excluder Conformable Endoprosthesis (CEXC) is designed to treat challenging infrarenal anatomy because of its active angulation control, repositionability, and enhanced conformability. This study evaluated 30 day and one year position and apposition of the CEXC in the infrarenal neck.

METHODS

Patients treated with the CEXC between 2018 and 2022 with an available 30 day computed tomography angiogram (CTA) were selected from four hospitals in a prospective registry. Endograft apposition (shortest apposition length [SAL]) and position (shortest fabric distance [SFD]) were assessed on the 30 day and one year CTAs. Maximum infrarenal aortic curvature was compared between the pre- and post-operative CTAs to evaluate conformability of the CEXC.

RESULTS

There were 87 patients with a 30 day CTA, and for 56 of these patients the one year CTA was available. Median (interquartile range [IQR]) pre-operative neck length was 22 mm (IQR 15, 32) and infrarenal angulation was 52° (IQR 31, 72). Median SAL was 21.2 mm (IQR 14.0, 29.3) at 30 days for all included patients. The SAL in 13 patients (15%) was < 10 mm at 30 days, and one patient had a SAL of 0 mm and a type Ia endoleak. There was no significant difference in SAL between patients within and outside instructions for use. The SAL significantly increased by 1.1 mm (IQR -2.3, 4.7; p = .042) at one year. The SAL decreased in seven patients (13%), increased in 13 patients (23%), and remained stable in 36 patients (64%). Median SFD was 2.0 mm (IQR 0.5, 3.6) at 30 days, which slightly increased by 0.3 mm (IQR -0.5, 1.8; p = .019) at one year. One patient showed migration (SFD increase ≥ 5 mm). Median endograft tilt was 15.8° (IQR 9.7, 21.4). Pre-operative maximum infrarenal curvature was 36 m-1 (IQR 26, 56) and did not significantly change thereafter.

CONCLUSION

In most patients, the CEXC was implanted close to the renal arteries, and sufficient (≥ 10 mm) post-operative apposition was achieved at 30 days, which slightly increased at one year. Post-operative endograft tilt was relatively low, and aortic geometry remained unchanged after implantation of the CEXC, probably due to its high conformability.

Local Anesthesia for Endovascular Repair of Abdominal Aortic Aneurysm Allows for Accurate Graft Deployment with Durable Results

BACKGROUND

Local anesthesia (LA) is sparsely used in endovascular aneurysm repair (EVAR) despite short-term benefit, likely secondary to concerns over patient movement preventing accurate endograft deployment. The objective of this study is to examine the association between anesthesia type and endoleak, sac regression, reintervention, and mortality.

METHODS

The Vascular Quality Initiative database was queried for all EVAR cases from 2014 to 2022. Patients were included if they underwent percutaneous elective EVAR with anatomical criteria within instructions for use of commercially approved endografts. Multivariable logistic regression with propensity score weighting was used to determine the association between anesthesia type on the risk of any endoleak noted by intraoperative completion angiogram and sac regression. Multivariable survival analysis with propensity score weighting was used to determine the association between anesthesia type and endoleak at 1 year, long-term reintervention, and mortality.

RESULTS

Thirteen thousand nine hundred thirty two EVARs met inclusion criteria: 1,075 (8%) LA and 12,857 (92%) general anesthesia (GA). On completion angiogram, LA was associated with fewer rates of any endoleaks overall (16% vs. 24%, P < 0.001). On multivariable analysis with propensity score weighting, LA was associated with similar adjusted odds of any endoleak on intraoperative completion angiogram (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.47-0.68) as well as combined type 1a and type 1b endoleaks (OR 0.72, 95% CI 0.47-1.09). Follow-up computed tomography imaging at 1 year was available for 4,892 patients, 377 (8%) LA and 4,515 (92%) GA. At 1 year, LA was associated with similar rate of freedom from any endoleaks compared to GA (0.66 [95% CI 0.63-0.69] vs. 0.71 [95% CI 0.70-0.72], P = 0.663) and increased rates of sac regression (50% vs. 45%, P = 0.040). On multivariable analysis with propensity score weighting, LA and GA were associated with similar adjusted odds of sac regression (OR 1.22, 95% CI 0.97-1.55). LA and GA had similar rates of endoleak at 1 year (hazard ratio [HR] 0.14, 95% CI 0.63-1.07); however, LA was associated with decreased hazards of combined type 1a and 1b endoleaks at 1 year (HR 0.87, 95% CI 0.80-0.96). LA and GA had similar adjusted long-term reintervention rate (HR 0.77, 95% CI 0.44-1.38) and long-term mortality (HR 1.100, 95% CI 079-1.25).

CONCLUSIONS

LA is not associated with increased adjusted rates of any endoleak on completion angiogram or at 1-year follow-up compared to GA. LA is associated with decreased adjusted rates of type 1a and type 1b endoleak at 1 year, but similar rates of sac regression, long-term reintervention, and mortality. Concerns for accurate graft deployment should not preclude use of LA and LA should be increasingly considered when deciding on anesthetic type for standard elective EVAR.

Comprehensive framework of factors accounting for worse aortic aneurysm outcomes in females: A scoping review

Sex-based outcome studies have consistently documented worse results for females undergoing care for abdominal aortic aneurysms. This review explores the underlying factors that account for worse outcomes in the females sex. A scoping review of studies reporting sex-based disparities on abdominal aortic aneurysms was performed. The review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews. Factors that account for worse outcomes in the females sex were identified, grouped into themes, and analyzed. Key findings of each study are reported and a comprehensive framework of these factors is presented. A total of 35 studies were identified as critical in highlighting sex-based disparities in care of patients with aortic aneurysms. We identified the following 10 interrelated themes in the chain of aneurysm care that account for differential outcomes in females: natural history, risk factors, pathobiology, biomechanics, screening, morphology, device design and adherence to instructions for use, technique, trial enrollment, and social determinants. Factors accounting for worse outcomes in the care of females with aortic aneurysms were identified and described. Some factors are immediately actionable, such as screening criteria, whereas device design improvement will require further research and development. This comprehensive framework of factors affecting care of aneurysms in females should serve as a blueprint to develop education, outreach, and future research efforts to improve outcomes in females.