Color Doppler ultrasound for surveillance following EVAR as the primary tool

Fenestrated Endovascular Aortic Aneurysm Repair Is Associated with Increased Sac Regression on Postoperative Volumetric Analysis Compared to Endovascular Aortic Aneurysm Repair

BACKGROUND

Endovascular aortic aneurysm repair (EVAR) is utilized to treat abdominal aortic aneurysms, while patients with short infrarenal necks can undergo fenestrated EVAR (FEVAR). Previous studies have demonstrated decreased aortic neck dilation for FEVAR compared to EVAR. Sac regression is a marker of success after EVAR; however, little is known regarding changes in sac volumetrics. This study compares aortic sac regression after EVAR versus FEVAR using volumetric analysis.

METHODS

A retrospective review of prospectively collected data from 120 patients who underwent EVAR was performed. Thirty patients underwent FEVAR (Cook Medical Inc, Bloomington, IN) and 90 patients underwent EVAR (30 each with Endurant [Medtronic, Dublin, Ireland], Excluder [Gore, Flagstaff, AZ], and Zenith [Cook]). Demographic data were analyzed. Using 3-dimensional reconstruction software, preoperative and postoperative aneurysm sac volumes were measured, in addition to aneurysm characteristics.

RESULTS

There were no differences in demographic or preoperative comorbidities. Preoperatively, FEVAR had greater percentage of thrombus within the sac by volume compared to EVAR (51.5% vs. 39.1%, P = 0.0002), and greater overall sac volume (240.8 ± 100.4 vs. 188.2 ± 82.4 cm3, P = 0.005). EVAR patients had greater number of lumbar arteries (7.26 ± 1.68 vs. 5.31 ± 1.93, P < 0.000001). On postoperative follow-up, FEVAR cases had greater sac regression compared to standard EVAR (-22.75 ± 25.7% vs. -5.98 ± 19.66%, P = 0.00031). The percentage of sac regression was greater when measured by volume compared to maximum diameter for FEVAR (-22.75 ± 25.7% vs. -13.90 ± 15.4%, P = 0.01) but not EVAR (-5.98 ± 19.7% vs. -4.51 ± 15.2%, P = 0.246). Those in the top tertile of percent volume of thrombus (>48.5%) were more likely to experience greater than 10% sac regression by volume (55% vs. 33.3%, P = 0.015). On multivariate analysis, FEVAR was associated with sac regression greater than 10% by volume (odds ratio [OR] 4.325, 95% confidence interval [CI] 1.346-13.901, P = 0.014), while endoleak (OR 0.162, 95% CI 0.055-0.479, P < 0.001) and 2 patent hypogastric arteries (OR 0.066, 95% CI 0.005-0.904, P = 0.042) were predictive against.

CONCLUSIONS

Fenestrated EVAR is associated with greater sac regression compared to EVAR on volumetric analysis. This difference may be attributable to decreased endotension within the aneurysm resulting from less aortic neck dilatation, while the greater proportion of thrombus may be a protective factor from growth. Patients being evaluated for EVAR with borderline neck anatomy should be considered for FEVAR given increased sac regression.

A Retrospective Analysis of Late Open Conversions Following Failed Endovascular Aneurysm Repair

Background

The incidence of late open surgical conversions (OSCs) has recently increased. Vascular surgeons face additional technical challenges in late conversion surgery of failed endovascular aneurysm repair (EVAR) due to the presence of a previously deployed endograft. Based on our institutional experience, this study aimed to delineate methods to improve late open conversion outcomes, proposing solutions for technical challenges.

Methods

All preoperative OSC data on failed EVARs operated in our Cardiovascular Surgery Clinic between January 2017 and January 2024 were evaluated retrospectively. Study endpoints included early (30-day or in-hospital) and late follow-up outcomes. Early outcomes included perioperative mortality and morbidities, intensive care unit (ICU) period, and length of hospital stay (LOS). The main outcome of interest during follow-up was overall survival.

Results

Sixteen patients in our hospital, comprising eight elective and eight emergency procedures, underwent OSCs following EVAR. The difference between the 30-day mortality rates for the elective and urgent late conversions was significant (p < 0.001). Of these patients, 15 were male, with a mean age of 70.8 years (range: 62-80). Preoperative cardiac shock status and low hematocrit level (<20%) were independent mortality factors (p < 0.001). The ICU period was 8.7 ± 5.3 days (2-20 days) on average, and LOS was 17.3 ± 8.4 (6-29 days) days on average. The mean time to open surgical conversion in this cohort was 44.4 ± 16.8 months. The 5-year overall survival rate was 43.75%.

Conclusions

The incidence of open surgical conversion is notably growing. Emergent open surgical conversions exhibit poorer mortality outcomes compared to elective procedures. Further data are essential to evaluate the ramifications of expanding the use of EVAR beyond the instructions for use (IFU) guidelines. The procedures involving patients who challenge the IFU criteria should be conducted at experienced centers and require close monitoring. Open surgical repair (OSR) as the initial treatment opportunity could be an alternative strategy for improving outcomes in this patient cohort.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Carbon Dioxide Guided Endovascular Aortic Aneurysm Repair in Impaired Renal Function: Propensity Score Matched Study

OBJECTIVE

Carbon dioxide (CO2) is the preferred contrast agent in patients with impaired renal function and or contrast allergy and, particularly, in patients who require large volumes of contrast for complex endovascular procedures. In this study, the aim was to clarify the possible protective effects of CO2 guided endovascular aneurysm repair (EVAR) for patients with impaired renal function by propensity score matching.

METHODS

A retrospective analysis of the database was performed for 324 patients having EVAR between January 2019 and January 2022. A total of 34 patients treated with CO2 guided EVAR were evaluated. This cohort was matched for age, sex, pre-operative serum creatinine levels and glomerular filtration rate (GFR) levels and specific comorbidities to obtain homogeneous groups that included only patients with impaired renal function (eGFR < 60 mL/min/1.73m2). The primary endpoint was to compare the decrease in eGFR from baseline and development of contrast induced nephropathy (CIN) using propensity score matching. Secondary endpoints were the need for renal replacement therapy, other peri-procedural morbidity and mortality.

RESULTS

Thirty-one patients (9.6%) of the total population developed CIN. There was no difference in the rate of CIN development between the standard EVAR group and the CO2 guided EVAR group in the unmatched population (10% vs. 3%, p = .15). After matching, the decrease in eGFR values after the procedure was more pronounced for the standard EVAR group (from 44 to 40 mL/min/1.73m2, interaction p = .034). Meanwhile, CIN development was more frequent for the standard EVAR group (24% vs. 3%, p = .027). In matched patients, early death did not differ between the groups (5.9% vs. 0, p = .15) CONCLUSION: Patients with impaired renal function are at higher risk of CIN after an endovascular procedure. CO2 guided EVAR is a safe, effective, and feasible treatment option, especially for patients with impaired renal function. CO2 guided EVAR may be a protective measure for contrast induced nephropathy.

Safety of Utilizing Ultrasound as the Sole Modality of Follow-Up after Endovascular Aneurysm Repair

BACKGROUND

Post endovascular aneurysm repair (EVAR), surveillance with computed tomography-aortography (CTA) remains the most common practice, per Society for Vascular Surgery (SVS) guidelines. Chronic exposure to both radiation and intravenous (IV) contrast has raised concerns about long-term CTA follow-up (FU). As we have selectively used ultrasound (US) as a sole modality for post-EVAR surveillance, we sought to review our outcomes in this subset of patients.

METHODS

Retrospective review of our institution's vascular database identified 213 EVAR patients from 2013 to 2021. Fenestrated-EVAR and snorkel reconstructions were excluded. Patient demographics/outcomes, abdominal aortic aneurysm (AAA) characteristics, and FU modalities and outcomes were analyzed. Unpaired Student's t-test, ANOVA, and chi-squared test were used to assess group differences.

RESULTS

Eighty-five of the 213 EVAR patients (39.9%) were lost to FU within 3 months. Among the 128 remaining patients, 91 underwent FU using initial US, while 37 patients underwent post-EVAR FU initially using CTA. There were no significant differences (P > 0.05) between patient age (75.5 ± 9.4 vs. 75.3 ± 8.5), body mass index (BMI) (27.7 ± 5.4 vs. 28.9 ± 7.4), or mean AAA size (5.6 ± 1.1 vs. 5.9 ± 1.2) in US-surveilled and computed tomography (CT)-surveilled groups, respectively. Of the 91 patients, initially surveilled with US, 15 patients demonstrated endoleak and/or AAA growth (>5 mm). The 15 patients with US-demonstrated endoleak and/or growth underwent confirmatory CTA, with 3 patients eventually requiring EVAR revision. Among 37 patients initially surveilled with CT, 10 demonstrated significant growth and 2 patients eventually required EVAR revision. There were no patients with AAA rupture during post-EVAR surveillance. FU data were analyzed among a select lower-risk group of patients (preoperative AAA diameter ≤5.5 cm, BMI ≤30, and no endoleak at completion of EVAR). Among this group, there were no surveilled patients who required EVAR reintervention, regardless of surveillance modality (US n = 32; CT n = 4). The average FU was 29.5 ± 26.4 months in the US group and 26.4 ± 22.3 months in the CT group (P > 0.05).

CONCLUSIONS

Although initial CT surveillance following EVAR remains ideal, in select lower-risk patients, US is a viable alternative even for the initial post-procedure study. Advantages include decreased radiation exposure and cost. Our data suggest that US is a safe sole modality for surveillance following EVAR in selective patients.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Colour Duplex and/or Contrast-Enhanced Ultrasound Compared with Computed Tomography Angiography for Endoleak Detection after Endovascular Abdominal Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis

This study aims to assess the role of Color Duplex Ultrasound with or without contrast media for surveillance following endovascular aortic aneurysm repair (EVAR). A systematic search of the literature published until April 2022 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The pooled rates of endoleak detection through Contrast-Enhanced or Color Duplex Ultrasound (CEUS or CDUS) and Computed Tomography Angiography (CTA) with 95% confidence intervals (CIs) were estimated using random-effect analysis. Thirty-eight studies were considered eligible for inclusion. The total number of patients in the included studies was 5214 between 1997 and 2021. The overall pooled rate of endoleak detection using CDUS and CTA was 82.59% and 97.22%, while the rates for CEUS and CTA were 96.67% and 92.82%, respectively. The findings of the present study support the use of the CEUS for endoleak detection. However, it should be integrated into institutional protocols for EVAR surveillance to further evaluate its clinical utility in the post-EVAR period before it can be recommended as the sole imaging modality after EVAR.

EVAR Follow-Up with Ultrasound Superb Microvascular Imaging (SMI) Compared to CEUS and CT Angiography for Detection of Type II Endoleak

The aim of this study was to evaluate the usefulness of superb microvascular imaging (SMI) versus contrast-enhanced ultrasound (CEUS) and compared to computed tomography angiography (CTA) as a reference standard, for detection of type II endoleak during follow-up of endovascular abdominal aortic aneurysm repair (EVAR). Between April 2017 and September 2020, 122 patients underwent post-EVAR follow-up with CTA at 3 months and with ultrasound SMI and CEUS at 4 months from the EVAR procedure. Aneurysmal sac diameter and graft patency were evaluated; endoleaks were assessed and classified. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were calculated both for SMI and CEUS and compared to CTA. Furthermore, the percentage of agreement and Cohen’s Kappa coefficient were calculated. CTA revealed 54 type II endoleaks. Ultrasound SMI and CEUS presented the same sensitivity (91.5%), specificity (100%), positive (100%), and negative (92.8%) predictive and accuracy (95.9%) value for detecting type II endoleak. The same percentage of agreement of 94.9% was found between SMI/CEUS, and CTA with a Cohen’s Kappa coefficient of 0.89. The diagnostic accuracy of SMI is comparable with CEUS in the identification of type II endoleaks after EVAR. Since SMI is less invasive, less expensive, and less time-consuming, this method may be considered to be a potential tool for monitoring patients after EVAR implantation.