Update on the Talent LPS AAA stent graft: results with "enhanced talent"

Statins Reduce Abdominal Aortic Aneurysm Growth, Rupture, and Perioperative Mortality: A Systematic Review and Meta-Analysis

Background

There are no recognized pharmacological treatments for abdominal aortic aneurysms (AAA), although statins are suggested to be beneficial. We sought to summarize the literature regarding the effects of statins on human AAA growth, rupture, and 30‐day mortality.

Methods and Results

We conducted a systematic review and meta‐analysis of randomized and observational studies using the Cochrane CENTRAL database, MEDLINE, and EMBASE up to June 15, 2018. Review, abstraction, and quality assessment were conducted by 2 independent reviewers, and a third author resolved discrepancies. Pooled mean differences and odds ratios with 95% confidence intervals were calculated using random effects models. Heterogeneity was quantified using the I² statistic, and publication bias was assessed using funnel plots. Our search yielded 911 articles. One case‐control and 21 cohort studies involving 80 428 patients were included. The risk of bias was low to moderate. Statin use was associated with a mean AAA growth rate reduction of 0.82 mm/y (95% confidence interval 0.33, 1.32, P=0.001, I²=86%). Statins were also associated with a lower rupture risk (odds ratio 0.63, 95% confidence interval 0.51, 0.78, P<0.0001, I²=27%), and preoperative statin use was associated with a lower 30‐day mortality following elective AAA repair (odds ratio 0.55, 95% confidence interval 0.36, 0.83, P=0.005, I²=57%).

Conclusions

Statin therapy may be associated with reduction in AAA progression, rupture, and lower rates of perioperative mortality following elective AAA repair. These data argue for widespread statin use in AAA patients.

Clinical Trial Registration

URL: http://www.crd.york.ac.uk. Unique identifier: CRD42017056480.

Tratamento endovascular da oclusão de ramo ilíaco de endoprótese bifurcada de aorta abdominal: trombectomia rotativa e aspirativa seguida de angioplastia com stent primário

A oclusão de ramo ilíaco de endoprótese bifurcada de aorta surge como complicação decorrente da correção endovascular do aneurisma de aorta abdominal e várias abordagens terapêuticas têm sido empregadas para o tratamento dessa complicação em casos de isquemia de membro inferior. Apresentamos dois casos de tratamento totalmente percutâneo da oclusão de ramo ilíaco de endoprótese de aorta abdominal com dispositivo de trombectomia rotativa e aspirativa seguida de angioplastia com stent primário, sem complicações operatórias.

Five-year results for the Talent enhanced Low Profile System abdominal stent graft pivotal trial including early and long-term safety and efficacy

OBJECTIVES

The pivotal trial of the Talent enhanced Low Profile System (eLPS; Medtronic Vascular, Santa Rosa, Calif) stent graft evaluated short and long-term safety and efficacy of endovascular aneurysm repair (EVAR). These data and a confirmatory group assessing the performance of the CoilTrac delivery system supported the United States premarket approval application for the device.

METHODS

The pivotal trial was a prospective, nonrandomized study conducted at 13 sites from February 2002 to April 2003. The study group (n = 166) underwent EVAR using the Talent eLPS stent graft. The control group (n = 243) underwent open surgical AAA repair. Data for this group were obtained from the Society for Vascular Surgery Endovascular AAA Surgical Controls project. Outcomes were compared at 30 days and 12 months. Additional 5-year follow-up was obtained for the eLPS group. A single-center cohort of 137 patients was the confirmatory group for the assessment of the clinical performance of the CoilTrac delivery system, with analysis of outcomes <or=30 days from the procedure.

RESULTS

AAA anatomy with neck length as short as 3 mm and maximum neck diameter of 32 mm were included in the eLPS group. EVAR was superior to open repair for periprocedural outcomes, including mean procedure duration (167.3 vs 196.4 minutes, P < .001), blood transfusion (18.2% vs 56.8%, P < .001), median intensive care unit stay (19.3 vs 74.3 hours, P < .001), and mean hospital stay (3.6 vs 8.2 days, P < .001). Freedom from major adverse events was 89.2% for EVAR at 30 days vs 44.0% (P < .001) and 81.3% vs 42.4% at 1 year (P < .001). Freedom from all-cause mortality and aneurysm-related mortality (ARM) was 93.7% and 98.2% for EVAR vs 92.4% and 96.7% for the controls. Through 5 years for the EVAR group, rates of freedom from all-cause mortality, ARM, aneurysm rupture, and conversion to surgery were 69.8%, 96.5%, 98.2%, and 99.1%, respectively, with one conversion to surgery, 25 secondary reinterventions, and five site-reported instances of stent graft migration. The technical success rate for the CoilTrac confirmatory group was 100%, with no aneurysm rupture or conversion to open repair at 30 days. The 30-day all-cause mortality rate was 1.5% (2 of 137).

CONCLUSIONS

In a population with challenging anatomic characteristics, EVAR with the Talent eLPS and use of the CoilTrac delivery system compared favorably with open repair through 1 year. Sustained protection from ARM, with minimal reinterventions, was attained through 5 years.

Endovascular Repair of Traumatic Thoracic Aortic Injuries: A Critical Appraisal

Blunt trauma to the thoracic aorta is life-threatening, with instant fatality in at least 75% of victims. If left untreated, nearly half of those who survive the initial injury will die within the first 24 hours. Surgical repair has been the standard treatment of blunt aortic injury, but immediate operative intervention is frequently difficult due to concomitant injuries. Although endovascular treatment of traumatic aortic disruption is less invasive than conventional repair via thoracotomy, this strategy remains controversial in young patients due to anatomical considerations and device limitations. This article reviews the likely advantages of endovascular interventions for blunt thoracic aortic injuries. Potential limitations and clinical outcomes of this minimally invasive technique are also discussed.

Implant Degradation and Poor Healing After Endovascular Repair of Abdominal Aortic Aneurysms: An Analysis of Explanted Stent-Grafts

PURPOSE

To study explanted stent-grafts to achieve a better understanding of the mechanisms of failure after endovascular treatment of abdominal aortic aneurysms (AAA).

METHODS

Twelve stent-grafts were harvested at autopsy (n=3) or during surgical conversion (n=9). Device alterations were investigated by macroscopic examination, radiography, and surface analysis techniques. Healing around the implants was studied via histology and immunohistochemistry, with particular attention to the stent-graft/tissue interface.

RESULTS

Degradation was more important with Vanguard stent-grafts (off the market) than with AneuRx and Talent stent-grafts, but rupture of nitinol wires and poor surface finish in Talent stent-grafts raise concern about their corrosion resistance and long-term stability. Poor healing was observed around stent-grafts even after several years of implantation, with absence of vascular smooth muscle cells, fibroblasts, and collagen formation. In addition to the well-known foreign body reaction around the graft, numerous polymorphonuclear cells characteristic of the first step of healing were present in tissues around stent-grafts retrieved at surgical conversion. Factors explaining the lack of tissue organization around stent-grafts are discussed.

CONCLUSION

The long-term stability of implants remains a concern and requires more transparency from manufacturers regarding the surface properties of their devices. Lack of neointima formation impairs biological fixation of the implant to the vessel wall, leading to possible endoleaks and migration. New-generation stent-grafts promoting biological fixation should be developed to improve clinical outcomes of this minimally invasive treatment.

Initial and Midterm Results for Repair of Aortic Diseases With Handmade Stent Grafts

BACKGROUND

The purpose of this study was to determine the initial and midterm results for repair of thoracic and abdominal aortic diseases using handmade stent-grafts (SGs).

METHODS AND RESULTS

Between 1999 and 2004, 41 consecutive patients (31 patients with thoracic and 10 patients with abdominal aortic disease) underwent endovascular stent-graft repair using handmade SGs. The follow-up averaged 24.8+/-17.6 months. The technical and initial clinical success rates were 82.9% (34/41) and 80.5% (33/41), respectively. Primary type I or III endoleaks occurred in 12.2% (5/41) of the patients. The hospital mortality rate was 4.9% (2/41). Persistent type I or III endoleaks occurred in 9.8% (4/41) and SG migrations occurred in 4.9% (2/41) of the patients. Open surgical conversion was undertaken in 12.2% (5/41) of the patients because of an endoleak and/or migration. The mean change observed in the aneurysm diameter was -6.2+/-10.5 mm, and shrinkage in the diameter occurred in 51.4% (18/35) of the cases. There was 1 patient death because of aneurysm rupture. Neither stent fracture nor graft hole was observed. The overall clinical success rate during follow-up was 78.0% (32/41).

CONCLUSION

The initial and midterm results obtained after repair of the aortic diseases using handmade SGs were considered to be satisfactory. More surgical experience and long-term patient follow-up are both required to further reassess the effect of this treatment.

Structural failures in abdominal aortic aneurysm stentgrafts: Threat to durability and challenge to technology

A variety of structural defects or failures have appeared in the majority of commercially developed stentgrafts for endoluminal abdominal aortic aneurysm (AAA) repair. Some have resulted in device withdrawal; others have been dealt with by device modification. Newer devices have been designed to avoid some of these failure modes but, because many have not become apparent until as late as 2 years, these corrective measures will require long-term follow-up to establish device durability. Typically, routine surveillance has missed these problems or discovered them late and, when fully investigated, most structural problems have been more prevalent than initially suspected and/or increased with time. However, analyses documenting the full extent and clinical consequences of these structural failures have not been openly reported. This lack of information, and the nature of the structural failures themselves, have undermined confidence in the durability of endovascular aneurysm repair (EVAR), mandated indefinite periodic surveillance, and further increased its costs. Prospects for controlling the described failure modes in the future are good in terms of most device- and operator-specific causes, but aneurysm-specific causes may be more difficult to overcome. Until durability is established by improved technology and long-term follow-up, a more conservative application of EVAR has been suggested, with its use limited primarily to patients with large AAAs (>5.5 cm diameter), favorable anatomy for EVAR, and associated comorbidities that significantly increase the patient's risk for open repair as well as decrease their longevity outlook. The history of these structural failures and the corrective measures taken, as well as their current impact on EVAR are presented in this article.

Clinical effect of abdominal aortic aneurysm endografting: 7-year concurrent comparison with open repair

OBJECTIVE

We compared the effectiveness and clinical outcome of open repair versus endovascular aortic aneurysm repair (EVAR) in achieving prevention of abdominal aortic aneurysm (AAA)-related death and graft-related complications.

METHODS

Over 7 years from 1997 to 2003, 1119 consecutive patients underwent elective treatment of infrarenal AAAs, 585 with open repair and 534 with EVAR. Patients were regularly followed up at 1, 6, 12 months, and every 6 months thereafter, in EVAR group, and at 3 and 12 months, and yearly thereafter after open repair. Preoperative, intraoperative, and follow-up data were stored in a prospective database.

RESULTS

Median follow-up was similar in the 2 groups: 33 months (interquartile range [IQR], 13-50 months) in the EVAR group vs 35 months (IQR, 15-54 months) in the open repair group. EVAR group patients were older than patients in the open repair group: 73 years vs 72 years (P = .04). There were statistical significant differences between the EVAR group and the open repair group with respect to AAA median diameter (52 mm vs 56 mm), coronary disease rate (46% vs 37%; P = .001), pulmonary disease rate (56% vs 38%; P < .0001), and American Society of Anesthesiologists IV score rate (16% vs 6%; P < .0001). Thirty-day mortality in the EVAR group was 0.9% (5 of 534 patients), compared with 4.1% (24 of 585 patients; P = .001) in the open repair group, and major morbidity was 9.1% (49 of 534 patients) vs 18.6% (109 of 585 patients; P < .0001), respectively. The incidence of secondary procedures in the EVAR group was 15.7%, compared with 3% in the open repair group (P < .0001). There were no deaths related to secondary procedures in either group. Six AAAs (1.1%) ruptured after EVAR, 3 of which were fatal; in the open repair group 1 patient (0.2%) underwent successful repeat operatation to treat iliac pseudoaneurysm rupture 5 years after the original procedure. Kaplan-Meier estimates for freedom from aneurysm-related death at 84 months were 97.5% in the EVAR group and 95.9% in the open repair group (log rank test, P = .008). Kaplan-Meier survival estimates at 84 months were 67.1% in the open repair group and 66.9% in the EVAR group (P = NS). At the same interval the risk for secondary procedures was 49.4% for the EVAR group and 7.1% for the open repair group. Of the 11 variables analyzed with logistic analysis, open surgery (hazard ratio [HR], 11; 95% confidence interval [CI], 2.5-54.2; P = .002), American Society of Anesthesiologists IV score (HR, 7.1; 95% CI, 2.7-18.8; P = .0001), and age (HR, 1.06; 95% CI, 1.04-1.13; P = .04) were positive independent predictors of perioperative mortality.

CONCLUSION

Our data suggest that at a maximum follow-up of 7 years, patients who undergo EVAR show lower perioperative and late aneurysm-related mortality compared with a younger and substantially healthier group of patients with aneurysms treated with open repair. The higher need for secondary procedures in the endovascular group did not affect superiority of the overall performance of EVAR in the early and late intervals.