Thromboembolic complications after endovascular repair of abdominal aortic aneurysm with neck thrombus

The Challenge of Treating Abdominal Aortic Aneurysms with Hostile Neck Anatomy: An Overview

Hostile aortic neck anatomy challenges the outcomes of endovascular abdominal aortic aneurysm repair (EVAR). Besides reverting to open surgical repair (OSR), thoughtful endograft selection and a number of advanced endovascular techniques have been suggested as potential solutions for preventing proximal seal zone complications, improving EVAR durability, and preventing aneurysm-related death. Each technique is associated with advantages and limitations and there has not been a credible direct comparison amongst them in the form of a well-designed prospective trial. The not infrequent presence of multiple hostile anatomic characteristics further complicates decision making and challenges the surgeon's skills. This paper serves as an overview of hostile neck anatomy and its implications on EVAR. We provide a concise literature review with the purpose of outlining the treatment modalities and outcomes in this patient population.

Is Evar Feasible in Challenging Aortic Neck Anatomies? A Technical Review and Ethical Discussion

Background: Endovascular aneurysm repair (EVAR) has become an accepted alternative to open repair (OR) for the treatment of abdominal aortic aneurysm (AAA) despite “hostile” anatomies that may reduce its effectiveness. Guidelines suggest refraining from EVAR in such circumstances, but in clinical practice, up to 44% of EVAR procedures are performed using stent grafts outside their instruction for use (IFU), with acceptable outcomes. Starting from this “inconsistency” between clinical practice and guidelines, the aim of this contribution is to report the technical results of the use of EVAR in challenging anatomies as well as the ethical aspects to identify the criteria by which the “best interest” of the patient can be set. Materials and Methods: A literature review on currently available evidence on standard EVAR using commercially available endografts in patients with hostile aortic neck anatomies was conducted. Medline using the PubMed interface and The Cochrane Library databases were searched from 1 January 2000 to 6 May 2021, considering the following outcomes: technical success; need for additional procedures; conversion to OR; reintervention; migration; the presence of type I endoleaks; AAA-related mortality rate. Results: A total of 52 publications were selected by the investigators for a detailed review. All studies were either prospective or retrospective observational studies reporting the immediate, 30-day, and/or follow-up outcomes of standard EVAR procedures in patients with challenging neck anatomies. No randomized trials were identified. Fourteen different endo-grafts systems were used in the selected studies. A total of 45 studies reported a technical success rate ranging from 93 to 100%, and 42 the need for additional procedures (mean value of 9.04%). Results at 30 days: the incidence rate of type Ia endoleak was reported by 37 studies with a mean value of 2.65%; 31 studies reported a null migration rate and 32 a null conversion rate to OR; in 31 of the 35 studies that reported AAA-related mortality, the incidence was null. Mid-term follow-up: the incidence rate of type Ia endoleak was reported by 48 studies with a mean value of 6.65%; 30 studies reported a null migration rate, 33 a null conversion rate to OR, and 28 of the 45 studies reported that the AAA-related mortality incidence was null. Conclusions: Based on the present analysis, EVAR appears to be a safe and effective procedure—and therefore recommendable—even in the presence of hostile anatomies, in patients deemed unfit for OR. However, in order to identify and pursue the patient’s best interest, particular attention must be paid to the management of the patient’s informed consent process, which—in addition to being an essential ethical-legal requirement to legitimize the medical act—ensures that clinical data can be integrated with the patient’s personal preferences and background, beyond the therapeutic potential of the proposed procedures and what is generically stated in the guidelines.

Five-year outcomes of the Bi- versus Trimodular EndurantTM stent-graft in 100 patients with infrarenal abdominal aortic repair

BACKGROUND

Recent studies on the Endurant™ endografts mainly compared outcomes of the bimodular stent-graft to other manufacturer's endografts or reported results for cases outside manufacturer's instructions for use (IFU), while data on the experience of standard endovascular aortic repair (EVAR) of infrarenal abdominal aortic aneurysms (AAA) inside manufacturer's IFU comparing the bi- with the trimodular device is limited.

METHODS

Inclusion criteria were: 1) infrarenal aneurysms (>50 mm diameter) treated by Endurant^TM II (END II) or Endurant^TM IIs (END IIs) stent-graft inside manufacturer's IFU; 2) available CTA with 1 mm reconstruction of the entire aorta prior to intervention. Endpoints comparing the devices included technical success, 30-day mortality, rate of complications (bleeding with conversion to open repair, stent-graft stenosis/occlusion, acute distal embolism, infection or postprocedural necessity of dialysis), endoleaks and reinterventions (5-year follow-up). Aneurysm sac diameters were compared between baseline preinterventional CTA and last post-interventional CTA.

RESULTS

One hundred patients (90% male, mean age 74 years) treated with END II (N.=66) or END IIs (N.=34) were included. Technical success was 99%. One procedure-related active bleeding occurred ending up in surgical conversion (END II N.=1). 30d mortality was 0%. No initial type I/III endoleaks were present. Re-interventions were required in 19/100 (19%) of patients (END II N.=10; END IIs N.=9, P=0.17). The outcome of EVAR including technical success, 30d mortality, rate of complications, endoleaks and re-interventions showed no significant differences comparing END II/IIs.

CONCLUSIONS

Five-year outcomes of EVAR show consistently safe and effective results for either END II or IIs device.

Effect of Atheromatous Aorta on Thromboembolic Complications after Endovascular Aortic Aneurysm

Objective: The purpose of this study was to evaluate the effect of atheromatous aorta on thromboembolic complications after endovascular aortic aneurysm repair (EVAR) and to assess the risk factors for these complications. Materials and Methods: This retrospective study included patients who underwent EVAR for an abdominal aortic aneurysm at the Shizuoka Red Cross Hospital from 2007 to 2018. We defined atheromatous aorta as a thoracic shaggy aorta or abdominal aorta with neck thrombus. The main outcome was renal dysfunction and peripheral embolization (thromboembolic complications). We compared the incidence of thromboembolic complications between patients with normal aorta and atheromatous aorta. Moreover, we assessed the risk factors associated with thromboembolic complications in patients with atheromatous aorta. Results: Patients with atheromatous aorta had significantly more thromboembolic complications, such as renal dysfunction (24.5% vs. 3.9%; P<0.001) and peripheral embolization (12.3% vs. 0.0%; P<0.001) than those with normal aorta, respectively. We identified no risk factors associated with thromboembolic complications in patients with atheromatous aorta. Conclusion: Atheromatous aorta increases the risk of thromboembolic complications after EVAR. However, there is no established therapy for these thromboembolic complications. Further studies are necessary to determine the appropriate therapy, including appropriate preoperative medication, to prevent these complications.

Acute Global Testicular Infarction Post-EVAR from Cholesterol Embolisation can be Mistaken for Torsion

Introduction

Endovascular aneurysm repair (EVAR) is the most commonly used approach for treatment of abdominal aortic aneurysms (AAA). Testicular infarction is a rare complication of EVAR. A novel case of acute global testicular infarction post-EVAR from cholesterol embolisation mimicking torsion is presented.

Report

A 75 year old man developed acute right testicular ischaemia requiring orchidectomy following EVAR of an infrarenal aortic aneurysm. The patient was initially diagnosed with testicular torsion as the aetiology of the infarction; however, on re-analysis of histopathology it was found to be secondary to cholesterol emboli.

Discussion

In patients complaining of groin/scrotal pain following EVAR, it is worth considering testicular ischaemia whether secondary to cholesterol embolisation or gonadal occlusion. Clinicians should be aware that clinical and radiological findings can mimic torsion as this affects management and outcome.

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Endovascular aneurysm repair (EVAR) is the most commonly used approach for repair of abdominal aortic aneurysms.

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Testicular ischaemia is a rare complication of EVAR.

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Clinical and radiological findings may mimic testicular torsion.

Gender Differences in Aortic Neck Morphology in Patients with Abdominal Aortic Aneurysms Undergoing Elective Endovascular Aneurysm Repair

BACKGROUND

Previous studies have demonstrated that women tend to have adverse aortic neck morphology leading to exclusion of some women from undergoing endovascular aneurysm repair (EVAR). The objective of this study is to investigate differences in aortic neck morphology in men versus women, changes in the neck morphology and sac behavior after EVAR, and investigate how these features may influence outcomes.

METHODS

We conducted a retrospective review of elective EVARs (2004-2013). We excluded patients who underwent elective EVAR with no postoperative imaging available and those patients with fenestrated repairs. Using TeraRecon and volumetric analysis, several features were investigated. These included percent thrombus, shape, length, angulation of the neck, and changes in neck and abdominal aortic aneurysm diameter.

RESULTS

A total of 146 patients were found to meet inclusion criteria (115 men and 31 women) with similar baseline characteristics. Neck angulation was greater in women (23.9° vs. 13.5°; P < 0.028). The percent thrombus in women was higher than men (35.4% vs. 31%; P < 0.02). Abdominal aneurysm's were smaller in women at 1 year (4.2 cm vs. 5.1 cm; P < 0.002), and secondary interventions were higher in men (11.3% vs. 0%; P < 0.05). Other features such as neck shape, changes in neck diameter, neck length, and percent oversizing of graft where not statistically different between genders.

CONCLUSIONS

Gender differences in neck characteristics and changes in neck morphology do not appear to adversely affect EVAR outcomes. Longer follow-up is necessary to further assess whether these findings are clinically durable.