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Simmering JA, de Vries M, Haalboom M, Reijnen MMPJ, Slump CH, Geelkerken RH. Geometrical Changes of the Aorta as Predictors for Thromboembolic Events After EVAR With the Anaconda Stent-Graft. J Endovasc Ther 2023; 30:904-919. [PMID: 35786215 PMCID: PMC10637097 DOI: 10.1177/15266028221105839] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Thromboembolic events (TE), including limb graft occlusion (LGO) and distal limb embolization (DLE), are common complications after endovascular aneurysm repair (EVAR). The aim of this study was to find predictors for TE in patients treated with the Anaconda stent-graft for infrarenal aneurysms. MATERIALS AND METHODS Geometrical and anatomical variables were retrospectively analyzed in a consecutive Anaconda cohort. Pre- and postoperative CT scans were used to derive geometrical parameters length, curvature, torsion, and tortuosity index (TI) from the center lumen lines (CLLs). Limb characteristics, pre-to-post EVAR and mid-term-follow-up changes in the parameters were evaluated for their predictive value for TE. RESULTS Eighty-four patients (mean age 74±8.3 years, 74 men) were enrolled. The risk of TE was lowered with pre-to-post implant decreasing TI (steps of 0.05: OR: 1.30, 95% CI: 1.01-1.66, p=0.04), pre-to-post implant decreasing mean curvature (OR: 1.08, 95% CI: 1.01-1.16, p=0.03), and a larger degree of circumferential common iliac artery (CIA) calcification (OR: 0.98, 95% CI: 0.97-1.00, p=0.03). The only LGO predictor was the caudal relocation of maximal curvature after EVAR (OR: 1.01, 95% CI: 1.00-1.01, p=0.04). Preventors of DLE were CIA diameter (OR: 0.87, 95% CI: 0.76-0.99, p=0.04), circumferential CIA calcification (OR: 0.97, 95% CI: 0.95-1.00, p=0.03), mean and maximal curvature of the preoperative aortoiliac trajectory (OR: 0.86, 95% CI: 0.79-0.94, p<0.01 and OR: 0.97, 95% CI: 0.95-1.00, p=0.03, respectively) and pre-to-postoperative decrease in mean curvature (OR: 1.11, 95% CI: 1.02-1.21, p=0.02). Midterm TE predictors were length (OR: 0.95, 95% CI: 0.89-1.01, p=0.08) and torsion maximum location (OR: 1.01, 95% CI: 0.99-1.01, p=0.10). CONCLUSION The present study confirms that treatment of infrarenal AAA with an Anaconda stent-graft is related to a relatively high TE rate which decreases with a pre-to-postoperative reduction in curvature and TI, and a larger degree of circumferential CIA calcification. In other words, more aortoiliac straightening and more circumferential CIA calcification may prevent TE development after EVAR with this stent-graft.
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Affiliation(s)
- Jaimy A. Simmering
- Division of Vascular Surgery, Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
- Multi-Modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Mattijs de Vries
- Division of Vascular Surgery, Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Marieke Haalboom
- Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Michel M. P. J. Reijnen
- Multi-Modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
- Division of Vascular Surgery, Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Cornelis H. Slump
- Robotics and Mechatronics (RaM) Group, Faculty of Electrical Engineering, Mathematics and Computer Science, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Robert H. Geelkerken
- Division of Vascular Surgery, Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
- Multi-Modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
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Simmering JA, Koenrades MA, Slump CH, Groot Jebbink E, Zeebregts CJ, Reijnen MMPJ, Geelkerken RH. Renal and Visceral Artery Configuration During the First Year of Follow-Up After Fenestrated Aortic Aneurysm Repair Using the Anaconda Stent-graft: A Prospective Longitudinal Multicenter Study With ECG-Gated CTA Scans. J Endovasc Ther 2023:15266028231209929. [PMID: 37933525 DOI: 10.1177/15266028231209929] [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: 11/08/2023]
Abstract
OBJECTIVE The performance of fenestrated endovascular aortic aneurysm repair (FEVAR) may be compromised by complications related to the dynamic vascular environment. The aim of this study was to analyze the behavior of FEVAR bridging stent configurations during the cardiac cycle and during follow-up to improve our understanding on treatment durability. DESIGN Twenty-one patients presenting with complex abdominal aortic aneurysms (AAAs; 9 juxtarenal/6 pararenal/3 paravisceral/1 thoracoabdominal aortic aneurysm type IV), treated with a fenestrated Anaconda (Terumo Aortic, Inchinnan, Scotland, UK) with Advanta V12 bridging stents (Getinge, Merrimack, NH, USA), were prospectively enrolled in a multicenter observational cohort study and underwent electrocardiogram (ECG)-gated computed tomographic angiography (CTA) preoperatively, at discharge, 7-week, and 12-month follow-ups. METHODS Fenestrated endovascular aortic aneurysm repair stability was assessed considering the following variables: branch angle as the angle between the aorta and the target artery, end-stent angle as the angle between the end of the bridging stent and the native artery downstream from it, curvature and tortuosity index (TI) to describe the bending of the target artery. Body-bridging stent stability was assessed considering bridging stent flare lengths, the distances between the proximal sealing stent-ring and fenestrations and the distance between the fenestration and first apposition in the target artery. RESULTS Renal branch angles significantly increased after FEVAR toward a perpendicular position (right renal artery from median 60.9°, inter quartile range [IQR]=44.2-84.9° preoperatively to 94.4°, IQR=72.6-99.8°, p=0.001 at 12-month follow-up; left renal artery [LRA], from 63.7°, IQR=55.0-73.0° to 94.3°, IQR=68.2-105.6°, p<0.001), while visceral branch angles did not. The mean dynamic curvature only decreased for the LRA from preoperative (3.0, IQR=2.2-3.8 m-1) to 12-month follow-up (1.9, IQR=1.4-2.6 m-1, p=0.027). The remaining investigated variables did not seem to show any changes over time in this cohort. CONCLUSIONS Fenestrated endovascular aortic aneurysm repair for complex AAAs using the Anaconda fenestrated stent-graft and balloon-expandable Advanta V12 bridging stents demonstrated stable configurations up to 12-month follow-up, except for increasing renal branch angles toward perpendicular orientation to the aorta, yet without apparent clinical consequences in this cohort. CLINICAL IMPACT This study provides detailed information on the cardiac-pulsatility-induced (dynamic) and longitudinal geometry deformations of the target arteries and bridging stents after fenestrated endovascular aortic aneurysm repair (FEVAR) up to 12-month follow-up. The configuration demonstrated limited dynamic and longitudinal deformations in terms of branch angle, end-stent angle, curvature, and tortuosity index (TI), except for the increasing renal branch angles that go toward a perpendicular orientation to the aorta. Overall, the results suggest that the investigated FEVAR configurations are stable and durable, though careful consideration of increasing renal branch angles and significant geometry alterations is advised.
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Affiliation(s)
- Jaimy A Simmering
- Department of Surgery (Division of Vascular Surgery), Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Maaike A Koenrades
- Department of Surgery (Division of Vascular Surgery), Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
- Medical 3D Lab, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Cornelis H Slump
- Robotics and Mechatronics (RaM) Group, Faculty of Electrical Engineering, Mathematics and Computer Science, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Erik Groot Jebbink
- Multi-modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
- Department of Surgery, Rijnstate, Arnhem, the Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Michel M P J Reijnen
- Multi-modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
- Department of Surgery, Rijnstate, Arnhem, the Netherlands
| | - Robert H Geelkerken
- Department of Surgery (Division of Vascular Surgery), Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
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Simmering JA, Zagers DA, Geelkerken RH, Kuipers H, te Riet o.g. Scholten GA, Reijnen MM, Slump CH. The influence of electrocardiogram-gated computed tomography reconstruction into 8 or 10 cardiac phases on cardiac-pulsatility-induced motion quantification of stent grafts in the aorta. JVS Vasc Sci 2023; 4:100131. [PMID: 38033397 PMCID: PMC10682660 DOI: 10.1016/j.jvssci.2023.100131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/25/2023] [Indexed: 12/02/2023] Open
Abstract
Objective The goal of this study was to determine to what extent aortic stent graft motion quantification is comparable between electrocardiogram (ECG)-gated computed tomography (CT) scans with reconstructions into 8 and 10 cardiac phases on CT scanners from two different vendors. Methods An experimental setup that induces motion of an aortic stent graft, according to a predefined aortic blood pressure wave, was placed in two CT scanners of different vendors. The stent graft motion was captured using an ECG-gated CT technique and quantified using dedicated analysis algorithms. The calculated motion amplitudes and total traveled path lengths of stent segmentations were compared between scans reconstructed into 8 and 10 phases and between the scanners, after validation with sensor measurements and repeated measurements. Results No difference in motion amplitudes in z-direction (craniocaudal direction) was observed between the reconstructions into 8 and 10 phases (0.02 mm; 95% confidence interval [CI], -0.01 to 0.05 mm; P = .358). The z-amplitudes differed by 0.04 mm (95% CI, 0.01-0.07 mm; P = .003) between the different CT scanners. Path lengths differed 0.07 mm (95% CI, 0.01-to 0.13 mm; P = .013) between the reconstructions into 8 and 10 phases and 0.13 mm (95% CI, 0.06-0.17 mm; P < .001) between the different scanners. Conclusions The motion amplitudes can accurately be compared between 8 and 10 phases and between the two scanners, without differences larger than the voxel size of 0.3 × 0.3 × 0.5 mm. Clinical motion analysis results of different ECG-gated CT scans and CT scanners can be compared up to the accuracy of the CT scan.
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Affiliation(s)
- Jaimy A. Simmering
- Division of Vascular Surgery, Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Deborah A. Zagers
- Division of Vascular Surgery, Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Robert H. Geelkerken
- Division of Vascular Surgery, Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Henny Kuipers
- Robotics and Mechatronics (RaM) Group, Faculty of Electrical Engineering, Mathematics and Computer Science, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Gerben A. te Riet o.g. Scholten
- Robotics and Mechatronics (RaM) Group, Faculty of Electrical Engineering, Mathematics and Computer Science, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Michel M.P.J. Reijnen
- Multi-modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
- Department of Surgery, Rijnstate, Arnhem, the Netherlands
| | - Cornelis H. Slump
- Robotics and Mechatronics (RaM) Group, Faculty of Electrical Engineering, Mathematics and Computer Science, Technical Medical Centre, University of Twente, Enschede, the Netherlands
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Differences in Cardiac-Pulsatility-Induced Displacement and Geometry Changes between the Cook ZBIS and Gore IBE: Postoperative Comparison Using ECG-Gated CTA Scans. Diagnostics (Basel) 2023; 13:diagnostics13030496. [PMID: 36766601 PMCID: PMC9914023 DOI: 10.3390/diagnostics13030496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
To what extent the stentgraft design of iliac branch devices (IBDs) relates to dynamic deformation is currently unknown. Therefore, this study aimed to quantify and compare displacement and geometry changes during the cardiac cycle of two common IBDs. This paper presents a two-center trial with patients treated with a Zenith bifurcated iliac side (ZBIS) or Gore iliac branch endoprosthesis (IBE). All patients underwent a retrospective electrocardiogram (ECG)-gated computed tomographic angiography (CTA) during follow-up. Cardiac-pulsatility-induced displacement was quantified for the following locations: (neo) bifurcation of the aorta, IBD flow divider, distal markers of the internal iliac artery (IIA) component and first IIA bifurcation. Geometrical parameters (length, tortuosity index, curvature and torsion) were quantified over centerlines. Displacement was more pronounced for the IBE than the ZBIS, e.g., craniocaudal displacement of 0.91 mm (0.91-1.13 mm) vs. 0.57 mm (0.40-0.75 mm, p = 0.004), respectively. The IBDs demonstrated similar geometrical parameters in the neo-common iliac artery and distal IIA, except for the larger dynamic curvature and torsion of the distal IIA in IBEs. The IBEs showed more dynamic length and curvature change compared to the ZBIS in the stented IIA. The IIA trajectory showed more pronounced deformation during the cardiac cycle after placement of an IBE than a ZBIS, suggesting the IBE is more conformable than the ZBIS.
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van Helvert M, Simmering JA, Koenrades MA, Slump CH, Heyligers JM, Geelkerken RH, Reijnen MM. Evaluation of electrocardiogram-gated computed tomography angiography to quantify changes in geometry and dynamic behavior of the iliac artery after placement of the Gore Excluder Iliac Branch Endoprosthesis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:454-463. [PMID: 35005875 DOI: 10.23736/s0021-9509.22.11980-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND The GORE® EXCLUDER® Iliac Branch Endoprosthesis (IBE) is designed to treat iliac aneurysms with preservation of blood flow through the internal iliac artery (IIA). Little is known about the influence of IBE placement on the IIA geometry. This study aimed to provide detailed insights in the dynamic behavior and geometry of the common iliac artery (CIA) and IIA trajectory and how these are influenced after treatment with an IBE. METHODS Pre- and postoperative electrocardiogram-gated computed tomography angiography (ECG-gated CTA) scans were acquired in a prospective study design and analyzed with in-house written algorithms designed for aorto-iliac and endoprosthesis deformation evaluation. Cardiac pulsatility-induced motion patterns and pathlengths were computed by tracking predefined locations on the aorto-iliac tract. Centerlines through the CIA-IIA trajectory were used to investigate the static and dynamic geometry, including curvature, torsion, length and Tortuosity Index (TI). RESULTS Fourteen CIA-IIA trajectories were analyzed before and after IBE placement. Cardiac pulsatility-induced motion and pathlengths increased after IBE placement, especially at mid IIA and the first IIA bifurcation (P≤0.04). After IBE placement, static and dynamic curvature, length and TI decreased significantly (P<0.05). Furthermore, the average dynamic torsion increased significantly (P=0.030). The remaining geometrical outcomes were not statistically significant. CONCLUSIONS The placement of an IBE device stiffens and straightens the CIA-IIA trajectory. Its relation with clinical outcome is yet to be investigated, which can be done thoroughly with the ECG-gated CTA algorithms used in this study.
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Affiliation(s)
- Majorie van Helvert
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Jaimy A Simmering
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands -
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Maaike A Koenrades
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
- Department of Medical Technology, Medical 3D lab, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Cornelis H Slump
- Robotics and Mechatronics Group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Jan M Heyligers
- Department of Vascular Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Robert H Geelkerken
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Michel M Reijnen
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, the Netherlands
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Simmering JA, Leeuwerke SJG, Meerwaldt R, Zeebregts CJ, Slump CH, Geelkerken RH. In Vivo Quantification of Cardiac-Pulsatility-Induced Motion Before and After Double-Branched Endovascular Aortic Arch Repair. J Endovasc Ther 2022:15266028221086474. [PMID: 35352980 DOI: 10.1177/15266028221086474] [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: 11/16/2022]
Abstract
The Relay®Branch stent-graft (Terumo Aortic, Sunrise, FL, USA) offers a custom-made endovascular solution for complex aortic arch pathologies. In this technical note, a modified electrocardiography (ECG)-gated computed tomography (CT)-based algorithm was applied to quantify cardiac-pulsatility-induced changes of the aortic arch geometry and motion before and after double-branched endovascular repair (bTEVAR) of an aortic arch aneurysm. This software algorithm has the potential to provide novel and clinically relevant insights in the influence of bTEVAR on aortic anatomy, arterial compliance, and stent-graft dynamics.
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Affiliation(s)
- Jaimy A Simmering
- Division of Vascular Surgery, Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands.,Multi-Modality Medical Imaging Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Steven J G Leeuwerke
- Division of Vascular Surgery, Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Robbert Meerwaldt
- Division of Vascular Surgery, Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cornelis H Slump
- Robotics and Mechatronics Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Robert H Geelkerken
- Division of Vascular Surgery, Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands.,Multi-Modality Medical Imaging Group, Technical Medical Centre, University of Twente, Enschede, The Netherlands
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Leeuwerke SJG, de Niet A, Geelkerken RH, Reijnen MMPJ, Zeebregts CJ. Incidence and predictive factors for endograft limb patency of the Fenestrated Anaconda™ endograft used for complex endovascular aneurysm repair. J Vasc Surg 2021; 75:1512-1520.e1. [PMID: 34921964 DOI: 10.1016/j.jvs.2021.11.066] [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: 06/12/2021] [Accepted: 11/12/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the incidence, risk factors and outcomes of treatment for limb occlusion in patients treated for complex (thoraco-)abdominal aortic aneurysms (AAA) with the Fenestrated Anaconda™. METHODS Between June 2010 and May 2018, 335 patients underwent elective fenestrated aortic aneurysm repair in 11 participating centers using the Fenestrated Anaconda™ with a median follow-up of 14.3 months (IQR 27.4). The primary outcome measure was freedom-from-limb-occlusion. Secondary outcome measures were freedom-from-limb-related-reintervention, secondary patency, and risk factors associated with limb occlusion. RESULTS Thirty (9.0%) patients presented with limb occlusion during follow-up with freedom-from-limb-occlusion of 98.5%, 91.2%, and 81.7% at 30-days, 1 and 5 years, respectively. In 87% of cases, no obvious cause for limb occlusion was documented. Primary occlusion occurred within 30-days in 36.7% and within 1 year in 80.0%. Twenty-three (6.9%) patients underwent an occlusion-related reintervention; seven (23.3%) patients were treated conservatively. Freedom-from-limb-occlusion-related-reintervention at 30-days, one and five years was 97.8%, 93.2% and 88.6%, respectively. Secondary patency was 91.3% after 1-month and 86.2% after 1 and 5 years, respectively. Female sex (OR 3.27 - 95% CI 1.28 to 8.34, P = .01) was a statistically significant predictor for limb occlusion. A higher percentage of thrombus in the aneurysm sac appeared to be protective for limb occlusion (0% compared to <25%: OR 0.22 - 95% CI 0.07 to 0.63, P = .01; 0% compared to 25-50%: OR 0.20 - 95% CI 0.07 to 0.57, P = .00 and 0% compared to >50%: OR 0.08 - 95% CI 0.02 to 0.38, P = .00), as did iliac angulation (OR 0.99 - 95% CI 0.98 to 1.00, P = .04). CONCLUSION Limb occlusion remains a significant impediment of endograft durability in patients treated with the Fenestrated Anaconda™, especially in female patients. Controversially, a high aneurysmal thrombus load and a high degree of iliac angulation appeared to be protective for limb occlusion, for which no obvious cause could be identified.
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Affiliation(s)
- S J G Leeuwerke
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - A de Niet
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - R H Geelkerken
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands; Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - M M P J Reijnen
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands; Department of Surgery, Rijnstate, Arnhem, the Netherlands
| | - C J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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