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Abdul-Malak OM, Cherfan P, Liang N, Eslami M, Singh M, Mohapatra A, Zaghloul M, Madigan M, Al-Khoury G, Makaroun M, Chaer RA. Serious Failure Modes After EVAR Are Device Specific. J Endovasc Ther 2024:15266028241248345. [PMID: 38733297 DOI: 10.1177/15266028241248345] [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: 05/13/2024]
Abstract
OBJECTIVES Type I and III endoleaks following endovascular aneurysm repair (EVAR) can lead to catastrophic events that require major re-interventions. We reviewed our experience with aortic endograft re-interventions for type I and III endoleaks and other serious failures among different devices. METHODS We retrospectively reviewed patients with a prior EVAR who underwent open conversion (OC) or major endovascular intervention (MEI) (re-lining, cuff/limb extension, parallel graft) for type I/III endoleaks at our institution from 2002 to 2019. Baseline characteristics, procedural details, re-interventions, and outcomes were collected. RESULTS A total of 229 patients (194 men) underwent re-interventions for type I and III endoleaks after EVAR (90 OC, 139 MEI) for devices implanted between 1997 and 2019. Average age at re-intervention was 78±8.5 years. A total of 135 (59%) were implanted at our institution, whereas 93 (41%) were referred. Median time to re-intervention was 4 years with 25% to 75% interquartile range (IQR) of 2.2-6.6 years. There was no significant difference in baseline demographics or type of re-interventions (OC/MEI) between device types. 42/229 (18%) presented with ruptured aneurysms, 20/229 (9%) were symptomatic, whereas the rest presented with asymptomatic radiographic findings. Type 1A endoleak was present in 146/229 (63.8%-72 with proximal migration), type IB in 46/229 (20.1%), type IIIA in 37/229 (16.6%), type IIIB in 15/229 (6.5%), and persistent aneurysm sac growth with no radiographic evidence of an endoleak in 6/229 (2.6%). Devices included most commercial products: AFX, Excluder, AneuRx, Ancure, Endurant, and Zenith. A smaller number of investigational devices accounted for the rest. Type 1A endoleak was the most common indication for re-intervention among all devices except for AFX and ancure devices, proximal migration was a frequent presentation with AneuRx. AFX devices more frequently presented with a type III and ancure devices more frequently presented with a type IB endoleak. CONCLUSIONS Serious failure modes after EVAR differ between endografts and occur throughout the follow-up period. This is important to guide targeted interrogation of surveillance studies and follow-up schedules, even for discontinued devices, as well as comparisons between various series and estimation of EVAR failure rates. CLINICAL IMPACT Surveillance after EVAR is critical for long term success of the repair, understanding of the differential modes of failure of every graft available is important in the longitudinal evaluation of these endografts. Equally important is the understanding of the modes of failure of legacy endografts that are no longer on the market but still being followed, in order to be able to tailor a surveillance regiemn and the evntual repair if needed.
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Affiliation(s)
- O M Abdul-Malak
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - P Cherfan
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - N Liang
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - M Eslami
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - M Singh
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - A Mohapatra
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Division of Vascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - M Zaghloul
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - M Madigan
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - G Al-Khoury
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - M Makaroun
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - R A Chaer
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Moulakakis KG, Lazaris AM, Georgiadis GS, Kakkos S, Papavasileiou VG, Antonopoulos CN, Papapetrou A, Katsikas V, Klonaris C, Geroulakos G. A Greek Multicentre Study Assessing the Outcome of Late Rupture After Endovascular Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2024; 67:756-764. [PMID: 38154499 DOI: 10.1016/j.ejvs.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 11/02/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Late rupture after endovascular aortic aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) is an increasing complication associated with a high mortality rate. This study aimed to analyse the causes and outcomes in patients with AAA rupture after EVAR. METHODS A multi-institutional Greek study of late ruptures after EVAR between 2008 - 2022 was performed. Primary outcomes were intra-operative and in hospital death. RESULTS A total of 70 patients presented with late rupture after EVAR (proportion of ruptured EVARs among all EVARs, 0.6%; 69 males; mean age 77.2 ± 6.7 years). The mean time interval between EVAR and late rupture was 72.3 months (range 6 - 180 months). In all cases the cause of rupture was the presence of an endoleak (type I, 73%) with sac enlargement. Moreover, 34% of subjects with rupture after EVAR had been lost to follow up and 32% underwent a secondary intervention. Additionally, 57 patients (81%) were treated by conversion to open surgical repair (COSR) and the remainder by endovascular correction of endoleak (ECE). Eleven intra-operative deaths (16%) were recorded. The overall in hospital mortality rate was 41% (23% ECE vs. 46% COSR; p = .21). Of the patients who presented as initially haemodynamically stable, 23% died during hospitalisation, while the respective mortality rate for patients who presented as unstable was 78% (odds ratio [OR] 11.8, 95% confidence interval [CI] 3.6 - 39.1; p < .001). Multivariable logistic regression analysis revealed that severity of haemodynamic shock was the most significant risk factor for intra-operative (OR 7.15, 95% CI 1.58 - 32.40; p = .010) and in hospital death (OR 9.53, 95% CI 2.79 - 32.58; p < .001). CONCLUSION These data underline the devastating prognosis of late rupture after EVAR. Haemodynamic status at presentation was an important predictive factor for death both in the ECE and COSR groups. Rigorous follow up and prompt evaluation of an unstable patient in case of rupture after EVAR is recommended.
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Affiliation(s)
- Konstantinos G Moulakakis
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, University of Patras Medical School, Patras, Greece.
| | - Andreas M Lazaris
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Stavros Kakkos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | | | - Constantine N Antonopoulos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasios Papapetrou
- Hellenic Vascular Registry (HEVAR); Vascular Surgery Clinic, K.A.T. General Hospital, Athens, Greece
| | - Vasilios Katsikas
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Gennimatas General Hospital of Athens, Athens, Greece
| | - Chris Klonaris
- Hellenic Vascular Registry (HEVAR); 2nd Department of Vascular Surgery, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - George Geroulakos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Zhang Y, Ji Y, Wu G, Zhang M, Li X, Zhou M. Open repair for Sac Expansion after EVAR. Ann Vasc Surg 2024:S0890-5096(24)00138-9. [PMID: 38615753 DOI: 10.1016/j.avsg.2024.01.023] [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: 11/21/2023] [Revised: 01/12/2024] [Accepted: 01/28/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND This study aimed to examine the outcomes of open surgery techniques involving sacotomy and suturing of the feeding vessels in patients with aneurysm sac expansion after endovascular aneurysm repair (EVAR). METHODS Fourteen consecutive patients treated with sacotomy and suturing of feeding vessels for expanding aneurysm sacs with type II endoleaks following EVAR, between January 2018 and December 2022, were retrospectively included. All patients underwent preoperative digital subtraction angiography, and attempts were made to embolize the thick feeding vessels to reduce intraoperative bleeding. Age, sex, comorbidities, clinical presentation, aneurysm sac increase, morbidity, mortality, and follow-up were recorded. RESULTS The median age of the patients was 72.89±5.13 years old, and 13 (92.9%) patients were male. The sac size at the time of the open procedure was 107.89±22.58 mm, and the extent of sac growth at the time of the open procedure was 37.50±18.29 mm. The initial technical success rate of laparotomy and open ligation of the culprit arteries causing type II endoleaks was 92.9% (13/14). Among the patients, five (35.7%) had been treated with interventional embolization before the open procedure. One endograft was removed and replaced by a bifurcated Dacron graft because of distal dislocation in one patient. All patients recovered, and no deaths were recorded postoperatively. No patients had an eventful postoperative course or any subsequent graft-related complications during follow-up. CONCLUSIONS Open surgical repair involving sacotomy and suturing of the feeding vessels appeared to have good outcomes in the treatment of patients with aneurysm sac expansion caused by type II endoleaks after EVAR. Preoperative embolization of feeding vessels can thus effectively reduce intraoperative bleeding.
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Affiliation(s)
- Yepeng Zhang
- Nanjing Medical University Gulou Clinical Medical College, Nanjing 210008, People's Republic of China
| | - Ye Ji
- Nanjing Medical University Gulou Clinical Medical College, Nanjing 210008, People's Republic of China
| | - Guangyan Wu
- Nanjing Medical University Gulou Clinical Medical College, Nanjing 210008, People's Republic of China
| | - Ming Zhang
- Nanjing Medical University Gulou Clinical Medical College, Nanjing 210008, People's Republic of China
| | - Xiaoqiang Li
- Nanjing Medical University Gulou Clinical Medical College, Nanjing 210008, People's Republic of China
| | - Min Zhou
- Nanjing Medical University Gulou Clinical Medical College, Nanjing 210008, People's Republic of China.
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Haidar H, Kapahnke S, Frese JP, Omran S, Mueller V, Hinterseher I, Sommerfeld M, Kaschina E, Konietschke F, Greiner A, Buerger M. Risk factors for elective and urgent open conversion after EVAR-a retrospective observational study. Vascular 2024; 32:243-253. [PMID: 36413465 PMCID: PMC11129523 DOI: 10.1177/17085381221141118] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) has become the standard procedure for treating infrarenal abdominal aortic aneurysms (AAA). Various associated complications can lead to open conversion (OC). Thorough follow-up after the procedure is mandatory for the early detection of complications. Persisting perfusion of the aneurysm, a so-called endoleak (EL), paired with structural instability because of aortic wall atrophy and impaired cell functionality induced by EVAR, results in a high risk for aortic rupture. PURPOSE The goal of this study was to detect the risk factors for elective and urgent OC as a result of EVAR-induced pathophysiological changes inside the aortic wall. RESEARCH DESIGN Retrospective data analysis was performed on all open aortic repairs from January 2016 to December 2020. DATA COLLECTION AND ANALYSIS Fifty patients were identified as treated by OC for failure of an infrarenal EVAR. The patients were divided into two subgroups, here depending on the urgency of surgery. Statistical analysis of patient characteristics and outcomes was performed. RESULTS The most common indications for OC were various types of EL (74%), resulting in an aortic rupture in 15 patients. Patients with insufficient or absent follow-up were treated more frequently in an emergency setting (16% vs. 63%). The mortality rate was higher in cases of emergency OC (3% vs. 26%). CONCLUSIONS Particularly in cases of insufficient or absent follow-up, complications such as EL pose an enormous risk for fatal aortic rupture.
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Affiliation(s)
- Haidar Haidar
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Sebastian Kapahnke
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Jan P Frese
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Safwan Omran
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Verena Mueller
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Irene Hinterseher
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Germany
| | - Manuela Sommerfeld
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pharmacology, Center for Cardiovascular Research (CCR), Berlin, Germany
| | - Elena Kaschina
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pharmacology, Center for Cardiovascular Research (CCR), Berlin, Germany
| | - Frank Konietschke
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, Institute of Medical Biometrics and Clinical Epidemiology and Berlin Institute of Health (BIH), Berlin, Germany
| | - Andreas Greiner
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Matthias Buerger
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Borgen L, Aasekjær K, Skoe ØW. Exploiting endovascular aortic repair as a minimally invasive method - Nine years of experience in a non-university hospital. Eur J Radiol Open 2023; 11:100522. [PMID: 37701925 PMCID: PMC10493885 DOI: 10.1016/j.ejro.2023.100522] [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: 02/02/2023] [Revised: 08/22/2023] [Accepted: 09/02/2023] [Indexed: 09/14/2023] Open
Abstract
Background At the introduction of endovascular aortic repair (EVAR) in 2013 in our non-university hospital, we established a quality registry to monitor our EVAR activity. Purpose To observe if we over time were able to exploit EVAR as a minimally invasive method in an elective as well as emergency setting, and to monitor our treatment quality in terms of complications, secondary interventions and mortality. Material and methods From November 2013 to March 2022, we treated 207 patients with EVAR, including six patients with rupture. Follow-up regimen was partly based on contrast-enhanced computer tomography, and partly on contrast-enhanced ultrasound in combination with plain radiography. Results During the observation period, the method of anesthesia changed from general, via spinal, to local anesthesia. The groin access changed from surgical cut down to percutaneous and the median length of postoperative stay decreased from 3 days to 1 day. EVAR on ruptured aneurysm was done for the first time in 2019. Endoleak was detected in 85 patients (42%) and 37 patients (18%) had one or more secondary interventions, of which 85% were endovascular. Estimated five-year survival was 72% in patients below 80 years of age and 45% in patients 80 years or older. Conclusion Nine years of experience enabled us to exploit EVAR's advantages as a minimally invasive method in an elective as well as emergency setting. Complications, secondary interventions and survival rates in our low volume non-university hospital matches results from larger vascular centers.
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Affiliation(s)
- Lars Borgen
- Department of Radiology, Drammen Hospital, Vestre Viken Health Trust, Dronning gaten 28, 3004 Drammen, Norway
| | - Kjartan Aasekjær
- Department of Radiology, Drammen Hospital, Vestre Viken Health Trust, Dronning gaten 28, 3004 Drammen, Norway
| | - Øyvind Werpen Skoe
- Department of Surgery, Drammen Hospital, Vestre Viken Health Trust, Dronning gaten 28, 3004 Drammen, Norway
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6
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Elsayed N, Alhakim R, Al Nouri O, Baril D, Weaver F, Malas MB. Perioperative and long-term outcomes after open conversion of endovascular aneurysm repair versus primary open aortic repair. J Vasc Surg 2023; 77:89-96. [PMID: 35934217 DOI: 10.1016/j.jvs.2022.07.172] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/15/2022] [Accepted: 07/24/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The use of endovascular abdominal aortic aneurysm repair (EVAR) has superseded that of open aneurysm repair (OAR) as the procedure of choice for abdominal aortic aneurysm repair. However, significant rates of late reintervention and aneurysm rupture have been reported after EVAR, resulting in the need for conversion to OAR (C-OAR). To assess the relative effects of C-OAR on patients, we compared the outcomes of these patients to those of patients who had undergone P-OAR. METHODS The data from all patients who had undergone C-OAR and P-OAR in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database from 2003 to 2018 were queried. Multivariable logistic regression and Kaplan-Meier survival and Cox proportional hazard regression analyses were used to assess the perioperative long-term outcomes. RESULTS A total of 4763 patients were included (91.4%, P-OAR; 8.6%, C-OAR). C-OAR was associated with a significant increase in the odds of perioperative mortality (odds ratio, 1.7; 95% confidence interval [CI], 1.1-2.7; P = .027) and renal complications (odds ratio, 1.5; 95% CI, 1.1-2; P = .004) vs P-OAR. At 5 years, conversion was associated with a higher risk of mortality (hazard ratio [HR], 1.5; 95% CI, 1.3-1.9; P < .001), aneurysmal rupture (HR, 1.9; 95% CI, 1.2-3.1; P = .007), and reintervention (HR, 1.4; 95% CI, 1.05-1.97; P = .022) compared with P-OAR. These results also persisted at 10 years, with conversion associated with a higher risk of mortality (HR, 1.5; 95% CI, 1.2-1.8; P < .001), rupture (HR, 1.8; 95% CI, 1.1-2.8; P = .018), and reintervention (HR, 1.5; 95% CI, 1.1-2.1; P = .010). CONCLUSIONS The results from the present study have demonstrated that C-OAR is associated with a significantly higher risk of perioperative morbidity and mortality compared with P-OAR. We found a significant increase in mortality, aneurysm rupture, and reintervention at 5 and 10 years of follow-up.
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Affiliation(s)
- Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Rami Alhakim
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Omar Al Nouri
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Donald Baril
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Fred Weaver
- Division of Vascular and Endovascular Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA.
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Ibrahim M, Silver M, Jacob T, Meghpara M, Almadani M, Shiferson A, Rhee R, Pu Q. Open conversion after failed endovascular aneurysm repair is increasing and its 30-day mortality is higher than that after primary open repair. J Vasc Surg 2022; 76:1502-1510. [PMID: 35709860 DOI: 10.1016/j.jvs.2022.04.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/26/2022] [Accepted: 04/27/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) has become the preferred treatment of abdominal aortic aneurysms (AAAs). Recent studies have demonstrated that cases of EVAR failure repair and subsequent open conversion have increased. The aim of the present study was to evaluate the national trend of annual cases and assess the 30-day outcomes of conversion to open repair after failed EVAR compared with primary open repair. METHODS The National Surgical Quality Improvement Program database was queried for relevant Current Procedural Terminology and International Classification of Diseases, Ninth and Tenth Revision, codes to identify patients who had undergone conversion to open repair or primary open repair of nonruptured AAAs from 2009 to 2018. The annual trend of cases was assessed, and the perioperative outcomes of both procedures were compared. Multivariable logistic regression analyses were conducted to identify independent perioperative factors associated with mortality. RESULTS Of the 9635 patients with nonruptured AAAs included in the present analysis, 9250 had undergone primary repair and 385 had required open conversion. During the 10-year period, the annual number of cases of open conversion had steadily increased and that of primary repair had decreased. The incidence of postoperative complications was similar between both groups, except for cardiac arrest, which had occurred more frequently in the open conversion group. The 30-day mortality was higher in the open conversion group than in the primary group (9.6% vs 3.9%; P < .0001). Open conversion was also independently associated with higher odds of death (adjusted odds ratio [OR], 2.1; 95% confidence interval [CI], 1.8-2.4; P < .0001). When the average mortality in both groups was compared between the first and last 5 years, no difference was found (open conversion: 9.8% vs 9.5% [P = 1.00]; primary repair: 3.6% vs 4.2% [P = .19]). Other perioperative factors independently associated with mortality included increased age (OR, 1.8; 95% CI, 1.5-2.1; P < .0001), American Society of Anesthesiologists class ≥III (OR, 2.7; 95% CI, 1.1-6.6; P = .029), insulin-dependent diabetes (OR, 2.0; 95% CI, 1.2-3.3; P = .005), chronic obstructive pulmonary disease (OR, 1.4; 95% CI, 1.1-1.8; P = .006), the presence of dyspnea at rest (OR, 3.3; 95% CI, 1.8-6.1; P < .0001), and a high preoperative hematocrit (OR, 0.94; 95% CI, 0.93-0.97; P < .0001). CONCLUSIONS Open conversion to treat nonruptured AAAs after failed EVAR was independently associated with higher mortality. Also, the annual cases of open conversion have continued to increase without any significant changes in postoperative mortality. This highlights the danger of open conversion and stresses the need for better solutions to prevent and manage EVAR failure.
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Affiliation(s)
- Mudathir Ibrahim
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Michael Silver
- Division of Biostatistics, Maimonides Medical Center, Brooklyn, NY
| | - Theresa Jacob
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY; Clinical and Translational Research Laboratories, Maimonides Medical Center, Brooklyn, NY
| | - Melissa Meghpara
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Mahmoud Almadani
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | | | - Robert Rhee
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Qinghua Pu
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY.
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Suckow BD, Scali ST, Goodney PP, Sedrakyan A, Mao J, Zheng X, Hoel A, Giles-Magnifico K, Cooper MA, Osborne NH, Henke P, Schanzer A, Marinac-Dabic D, Stone DH. Contemporary incidence, outcomes, and survival associated with endovascular aortic aneurysm repair conversion to open repair among Medicare beneficiaries. J Vasc Surg 2022; 76:671-679.e2. [PMID: 35351602 PMCID: PMC10336856 DOI: 10.1016/j.jvs.2022.02.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/05/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The widespread application of endovascular abdominal aortic aneurysm repair (EVAR) has ushered in an era of requisite postoperative surveillance and the potential need for reintervention. The national prevalence and results of EVAR conversion to open repair, however, remain poorly defined. The purpose of this analysis was to define the incidence of open conversion and its associated outcomes. METHODS The SVS Vascular Quality Initiative EVAR registry linked to Medicare claims via Vascular Implants Surveillance and Interventional Outcomes Network was queried for open conversions after initial EVAR procedures from 2003 to 2016. Cumulative conversion incidence within up to 5 years after EVAR and outcomes after open intervention were determined. Multivariable logistic regressions were used to identify independent predictors of conversion and mortality. RESULTS Among 15,937 EVAR patients, 309 (1.9%) underwent an open conversion: 43% (n = 132) early (<30 days) and 57% (n = 177) late (>30 days). The longitudinally observed rate of conversion was constant over time, as well as by geographic region. Independent predictors of conversion included female sex (hazard ratio [HR], 1.49; P < .001), aneurysm diameter or more than 6.0 cm at the time of index EVAR (HR, 1.74; P < .001), nonelective repair (compared with elective presentation: HR, 1.72; P < .001), and aortouni-iliac repairs (HR, 2.19; P < .001). In contrast, adjunctive operative procedures such as endo-anchors or cuff extensions (HR, 0.62; P = .06) were protective against long-term conversion. Both early (HR, 1.6; P < .001) and late (HR, 1.26; P = .07) open conversions were associated with significant 30-day (total cohort, 15%) and 1-year mortality (total cohort, 25%). Patients undergoing open conversion experienced high rates of 30-day readmission (42%) and cardiac (45%), renal (32%), and pulmonary (30%) complications. CONCLUSIONS This large, registry-based analysis is among the first to document the incidence and outcomes for open conversion after EVAR in a national cohort with long-term follow-up. Importantly, women, patients with large aneurysms, and complex anatomy, as well as urgent or emergent EVARs are at an increased risk for open conversion. It seems that more conversions are performed in the early postoperative period, despite perceptions that conversion is a delayed phenomenon. In all instances, conversion is associated with significant morbidity and mortality and highlights the importance of appropriate patient selection at the time of index EVAR.
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Affiliation(s)
- Bjoern D Suckow
- Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY
| | - Jialin Mao
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY
| | - Xinyan Zheng
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY
| | - Andrew Hoel
- Division of Vascular Surgery, Northwestern University, Chicago, IL
| | | | - Michol A Cooper
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | | | - Peter Henke
- Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Andres Schanzer
- Division of Vascular Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Danica Marinac-Dabic
- Office of Clinical Evidence, US Food and Drug Administration, CDRH, Silver Springs, MD
| | - David H Stone
- Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
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Shiraev TP, de Boer M, Joseph S, Loa J, Qasabian R. Aortic graft explants - A single institution analysis of incidence and outcomes. Vascular 2022; 31:433-440. [PMID: 35103533 DOI: 10.1177/17085381211068219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Explantation of both endovascular endovascular aneurysm repair and open aortic grafts is a procedure associated with high peri-operative risk, and the current study sought to determine the outcomes and trends over time in these patients. METHODS This study examined data from all patients undergoing explant of an aortic graft (both open and endovascular) between January 2004 and December 2020 at a single centre. Variables analysed included comorbidities, duration to and indication for explantation, type of revascularization, in-hospital complications and mortality, duration of hospital and ICU stay, and out-patient mortality. RESULTS Of 688 open and 1352 EVARs performed, 46 patients underwent 48 explants. Five were open grafts and 43 were endografts, equating to an explant rate of 0.73% of open and 3.18% EVARs. Average time to explant was 70 months, with patients presenting electively having a significantly longer duration to representation than those presenting emergently (51 vs 44 months, p=0.003). Indication for explant was endoleak in 70%, infection in 23%, and occlusion in 6%. Of the endoleaks, 61% of were Type 1, 22% Type II, 11% Type IV, and 6% Type V. On representation, 17 patients (35%) were symptomatic. Overall mortality rate was 8.3%, with a trend for higher mortality in emergent than elective presentations (11.8 vs 6.5%, p=0.55). There was no change in explant rate over time. CONCLUSIONS Elective aortic graft explantation is associated with low mortality, despite its complexity and patient comorbidities. Patients presenting with symptoms suffered higher mortality and a longer post-operative course, suggesting that aortic graft explantation should be considered sooner rather than later, rather than persisting with repeated endovascular management.
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Affiliation(s)
- Timothy P Shiraev
- Vascular Surgery, 2205Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,523002The University of Notre Dame, Sydney
| | - Madeleine de Boer
- Vascular Surgery, 2205Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Simon Joseph
- Vascular Surgery, 2205Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Jacky Loa
- Vascular Surgery, 2205Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Raffi Qasabian
- Vascular Surgery, 2205Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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10
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Kontopodis N, Galanakis N, Ioannou CV, Tsetis D, Georgiadis GS, Antoniou GA. Meta-Analysis of the Crossed Versus Standard Limb Configuration in Endovascular Aneurysm Repair. Ann Vasc Surg 2021; 80:358-369. [PMID: 34788700 DOI: 10.1016/j.avsg.2021.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/24/2021] [Accepted: 10/05/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To investigate whether the crossed-limb technique confers better or worse clinical outcomes compared to the standard straight limb configuration in standard endovascular aneurysm repair (EVAR). METHODS We conducted a systematic review to identify studies comparing outcomes of EVAR with the crossed versus standard limb configuration. MEDLINE, EMBASE, CINAHL, and CENTRAL were searched in March 2021 using the Healthcare Databases Advanced Search interface developed by the National Institute for Heath and Care Excellence. The risk of bias was assessed with the Newcastle-Ottawa scale (NOS) and the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) tool. Summary estimates were calculated using the odds ratio (OR), risk difference (RD), or mean difference (MD) and 95% confidence interval (CI), applying the Mantel-Haenszel or inverse variance statistical method. Random-effects models were employed. RESULTS Four observational studies qualified for inclusion, reporting a total of 1132 patients. All presented contemporary experiences. Baseline clinical characteristics were largely similar between patients with and without the crossed-limb configuration, but the anatomy tended to be less favourable in patients treated with the crossed-limb technique. No statistically significant difference was found in the primary outcomes: limb occlusion (OR 1.44, 95% CI 0.65 - 3.19), type Ib endoleak (RD 0.01, 95% CI -0.03 - 0.04), type III endoleak (RD 0.01, 95% CI -0.01 - 0.03); or secondary outcomes: perioperative mortality (RD 0.00, 95% CI -0.03 - 0.03), type Ia endoleak (RD 0.00, 95% CI -0.03 - 0.02), type II endoleak (OR 1.38, 95% CI 0.51 - 3.74), procedure duration (MD 18.07 min, 95% CI -1.14-37.29). Inconsistency across studies was low for all outcomes. The studies were judged to be of high quality on the NOS. The main bias identified using the ROBINS-I tool was due to confounding. CONCLUSIONS The crossed-limb technique was not found to confer inferior clinical outcomes in the medium term compared to the standard limb configuration in patients who undergo standard EVAR.
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Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University General Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Nikolaos Galanakis
- Interventional Radiology Unit, Department of Medical Imaging, University General Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University General Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Dimitrios Tsetis
- Interventional Radiology Unit, Department of Medical Imaging, University General Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Division of Cardiovascular Sciences, School of Medical Sciences, The University of Manchester, Manchester, United Kingdom.
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11
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Jacobs CR, Scali ST, Khan T, Cadavid F, Staton KM, Feezor RJ, Back MR, Upchruch GR, Huber TS. EVAR Conversion is an Increasingly Common Indication for Open AAA Repair. J Vasc Surg 2021; 75:144-152.e1. [PMID: 34314833 DOI: 10.1016/j.jvs.2021.07.121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 07/15/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Although EVAR re-intervention is common, conversion to open repair(EVAR-c) occurs less frequently but can be associated with significant technical complexity and perioperative risk. There is a paucity of data highlighting the evolution of peri-procedural results surrounding EVAR-c and change in practice patterns, especially for referral centers that increasingly manage EVAR failures. The purpose of this analysis was to perform a temporal analysis of our EVAR-c experience and describe changes in patient selection, operative details and outcomes. METHODS A retrospective single center review of all open AAA repairs was performed(2002-2019) and EVAR-c procedures were subsequently analyzed. EVAR-c patients(n=184) were categorized into two different eras(2002-2009, n=21; 2010-2019, n=163) for comparison. Logistic regression and Cox proportional hazards modeling were used for risk-adjusted comparisons. RESULTS A significant increase in EVAR-c as an indication for any type of open aneurysm repair was detected(9%→27%;p<.001). Among EVAR-c patients, no change in age or individual comorbidities was evident[mean age: 71±9 years]; however, the proportion of female subjects(p=.01) and ASA classification >3 declined(p=.05). There was no difference in prevalence[50% vs. 43%;p=.6] or number[median-1.5(0, 5)] of pre-admission EVAR re-interventions; however, time to re-intervention decreased(median: 23[6,34] vs. 0[0,22] months;p=.005). In contrast, time to EVAR-c significantly increased(median: 16[9,39]vs. 48[20,83]-months;p=.008). No difference in frequency of non-elective presentation[mean-52%;p=.9] or indication was identified but a trend toward increasing mycotic EVAR-c was observed(5% vs. 15%;p=.09). Use of retroperitoneal exposure(14% vs. 77%;p<.0001), suprarenal cross-clamp application[6286%;p=.04] and visceral-ischemia time(median: 0[0,11] vs. 5[0,20]min;p=.05) all increased. In contrast, estimated blood loss(P-trend=.03) and procedure-time(p=.008) decreased. The unadjusted elective 30-day mortality rate improved but did not reach statistical significance[elective: 10% vs. 5%;p=.5] with no change for non-elective operations[18% vs. 16%;p=.9]. However, a significantly decreased risk of complications was evident(OR 0.88, 95%CI .8-.9;p=.01). One and 3-year survival was similar over time. CONCLUSION EVAR-c is now a common indication for open AAA repair. Patients frequently present non-electively and at increasingly later intervals after their index EVAR. Despite increasing technical complexity, decreased complication risk and comparable survival can be anticipated when patients are managed at a high-volume aortic referral center.
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Affiliation(s)
- Christopher R Jacobs
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville.
| | - Tabassum Khan
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Felipe Cadavid
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Kyle M Staton
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Robert J Feezor
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Gilbert R Upchruch
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
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12
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Xodo A, D'Oria M, Squizzato F, Antonello M, Grego F, Bonvini S, Milite D, Frigatti P, Cognolato D, Veraldi GF, Perkmann R, Garriboli L, Jannello AM, Lepidi S. Early and mid-term outcomes following open surgical conversion after failed endovascular aneurysm repair from the "Italian North-easT RegIstry of surgical Conversion AfTer Evar" (INTRICATE). J Vasc Surg 2021; 75:153-161.e2. [PMID: 34182022 DOI: 10.1016/j.jvs.2021.05.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 05/21/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To report the early and mid-term outcomes following open surgical conversion (OSC) after failed endovascular aortic repair (EVAR) using data from a multicentric registry. METHODS A retrospective study was carried out on consecutive patients undergoing OSC after failed EVAR at eight tertiary vascular units from the same geographic area in the North-East of Italy, from April 2005 to November 2019. Study endpoints included early and follow-up outcomes. RESULTS 144 consecutive patients were included in the study. Endoleaks were the most common indication for OSC (50.7%), with endograft infection (24.6%) and occlusion (21.9%) being the second most prevalent causes. The overall rate of 30-day all-cause mortality was 13.9% (n=20); 32 patients (22.2%) experienced at least one major complication. Mean length of stay (LoS) was 13 ± 12.7 days. On multivariate logistic regression, age (OR 1.09, 95% CI 1.01-1-19, p= .02), renal clamping time (OR 1.07, 95% CI 1.02-1.13, p= .01), and suprarenal/celiac clamping (OR 6.66, 95% CI 1.81-27.1, p= .005) were identified as independent predictors of peri-operative major complications. Age was the only factor associated with peri-operative mortality at 30 days. Renal clamping time > 25 minutes had sensitivity of 65% and specificity of 70% in predicting the occurring of major adverse events (AUC 0.72; 95% CI 0.61-0.82). At 5 years, estimated survival was significantly lower for patients treated due to aortic rupture/dissection (28%, 95% CI 13-61), compared to patients in whom the indication for treatment was endoleak (54%, 95% CI 40-73), infection (53%, 95% CI 30-94), or thrombosis (82%, 95% CI 62-100; p= .0019). 5-year survival rates were significantly lower in patients who received emergent treatment (28%, 95% CI 14-55) as compared with those who were treated in urgent (67%, 95% CI 48-93) or elective setting (57%, 95% CI 43-76; p= .00026). Subjects who received suprarenal/celiac (54%, 95% CI 36-82) or suprarenal (46%, 95% CI 34-62) aortic cross-clamping had lower survival rates at 5 years than those whose aortic-cross clamp site was infrarenal (76%, 95% CI 59-97; p= .041). Using multivariate Cox Proportional Hazard, older age and emergency setting were independently associate with higher risk for overall 5 years mortality. CONCLUSIONS OSC after failed EVAR was associated with relatively high rates of early morbidity and mortality, particularly for emergency setting surgery. Endoleaks with secondary sac expansion were the main indication for OSC and suprarenal aortic cross-clamping was frequently required. Endograft infection and emergent treatment remained associated with poorer short-term and long-term survival.
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Affiliation(s)
- Andrea Xodo
- Vascular and Endovascular Surgery Division, Padova University, School of Medicine, Padova, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University of Trieste Medical School, Trieste, Italy
| | - Francesco Squizzato
- Vascular and Endovascular Surgery Division, Padova University, School of Medicine, Padova, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Division, Padova University, School of Medicine, Padova, Italy
| | - Franco Grego
- Vascular and Endovascular Surgery Division, Padova University, School of Medicine, Padova, Italy
| | - Stefano Bonvini
- Department of Vascular Surgery, Santa Chiara Hospital, Trento, Italy
| | - Domenico Milite
- Operative Unit of Vascular and Endovascular Surgery, "S. Bortolo" Hospital, Vicenza, Italy
| | - Paolo Frigatti
- Vascular Surgery Department, University Hospital of Udine, Udine, Italy
| | - Diego Cognolato
- Vascular Surgery Department, "S. Bassiano" Hospital, Bassano del Grappa, Italy
| | | | | | - Luca Garriboli
- Department of Vascular Surgery, IRCCS Sacro Cuore Don Calabria, Negrar, Verona, Italy
| | | | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University of Trieste Medical School, Trieste, Italy.
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13
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Kasprzak PM, Pfister K, Kuczmik W, Schierling W, Sachsamanis G, Oikonomou K. Novel Technique for the Treatment of Type Ia Endoleak After Endovascular Abdominal Aortic Aneurysm Repair. J Endovasc Ther 2021; 28:519-523. [PMID: 33899573 PMCID: PMC8276339 DOI: 10.1177/15266028211010469] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose Open surgical repair of type Ia endoleak after endovascular aortic aneurysm repair/sealing (EVAR/EVAS) is associated with significant perioperative mortality and morbidity. Current endovascular redo techniques face limitations, especially when the infrarenal landing zone is inadequate and the previous endograft is rigid and features a short or no main body. We present a novel concept for the treatment of type Ia endoleak using a custom-made branched device. Technique The 5-branch-device (Cook Medical, Bloomington, IN, USA) consists of a nitinol skeleton with branches, covered with a low-profile polyester fabric loaded in an 18F sheath. The device features a minimum of 2 proximal sealing stents and includes branches for renovisceral vessels as well as an additional 8 mm branch for the contralateral iliac limb. Implantation and sealing in the renovisceral vessels is carried out in standard fashion, using transfemoral and transaxillary access. Distal sealing is achieved by tapering the branched component into the ipsilateral iliac limb and using a bridging balloon-expandable or self-expandable stent-graft through the additional branch to the preexisting contralateral iliac limb. Conclusion Treatment of type Ia endoleak with a new custom-made device enables sufficient proximal seal while minimizing suprarenal aortic coverage and facilitates adequate component overlap. The low profile branched design accommodates implantation through the preexisting endograft and catheterization of target vessels.
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Affiliation(s)
- Piotr M Kasprzak
- Department of Vascular Surgery, University Medical Centre Regensburg, Germany
| | - Karin Pfister
- Department of Vascular Surgery, University Medical Centre Regensburg, Germany
| | - Waclaw Kuczmik
- Department of General, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, Katowice, Poland
| | - Wilma Schierling
- Department of Vascular Surgery, University Medical Centre Regensburg, Germany
| | | | - Kyriakos Oikonomou
- Department of Vascular Surgery, University Medical Centre Regensburg, Germany
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14
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Sato H, Fukada J, Tamiya Y. Impact of Instructions for Use and Endoleaks On Long-Term Mortality After Treatment for Abdominal Aortic Aneurysm. Ann Vasc Surg 2021; 76:309-317. [PMID: 33905857 DOI: 10.1016/j.avsg.2021.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/16/2021] [Accepted: 03/25/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We reported the clinical outcomes after open repair and endovascular aortic repair for abdominal aortic aneurysm and analyzed the risk factors for all-cause mortality and endoleak after endovascular aortic repair. METHODS Patients who underwent elective treatment for abdominal aortic aneurysm from January 2009 to March 2020 were included in this study. The treatment was according to a procedure selection algorithm based on the Society for Vascular Surgery comorbidity scores and instructions for use. All patients were divided into open repair and endovascular aortic repair groups, and the clinical results were compared between the groups. RESULTS Of the 278 patients, 116 patients (41.9%) underwent open repair, and 161 patients (58.1%) underwent endovascular aortic repair. The cumulative survival rate with endovascular aortic repair was 78.6%. In the Cox proportional hazard analysis, hemodialysis (hazard ratio = 4.56; 95% confidence interval = 1.5-14.0) and the presence of type I or III endoleak (hazard ratio = 5.7; 95% confidence interval = 1.50-14.5) were independent risk factors for all-cause mortality. The Society for Vascular Surgery comorbidity score was not an independent risk factor (hazard ratio = 1.11; 95% confidence interval = 1.0-1.2). In the multivariate logistic regression analysis to identify the risk factors for type I or III endoleak after endovascular aortic repair, anticoagulation drug therapy (odds ratio = 3.99; 95% confidence interval = 1.8-8.9), untreated thoracic aortic aneurysm (odds ratio = 4.8; 95% confidence interval = 1.8-17.3), and outside instruction for use for the proximal neck (odds ratio = 5.8; 95% confidence interval = 2.3-9.8) were independent risk factors. CONCLUSIONS We analyzed the risk factors for all-cause mortality after treatment and endoleak after endovascular aortic repair. The results indicated that the instructions for use should be respected to reduce the frequency of endoleaks and that open repair should be chosen more often to improve late survival.
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Affiliation(s)
- Hiroshi Sato
- Department of Cardiovascular Surgery, Otaru General Hospital, Otaru, Hokkaido, Japan.
| | - Joji Fukada
- Department of Cardiovascular Surgery, Otaru General Hospital, Otaru, Hokkaido, Japan
| | - Yukihiko Tamiya
- Department of Cardiovascular Surgery, Otaru General Hospital, Otaru, Hokkaido, Japan
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15
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Mortola L, Ferrero E, Quaglino S, Ferri M, Viazzo A, Manzo P, Gaggiano A. Management of Nellix migration and type Ia endoleak from proximal endovascular aneurysm sealing relining to late open conversion. J Vasc Surg 2021; 74:1204-1213. [PMID: 33684472 DOI: 10.1016/j.jvs.2021.02.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 02/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite promising early results, mid-term failures of the Nellix endovascular aneurysm sealing (EVAS) system (Endologix Inc, Irvine, Calif) have been reported at higher than expected rates. The management of proximal endoleaks and migration differs from those after conventional endovascular aortic aneurysm repair (EVAR) owing to the peculiar design of the Nellix device. In the present study, we report a monocentric experience in the management of EVAS complications using various techniques. We also performed a comprehensive review of the relevant literature on both open surgical and endovascular management of proximal failure of EVAS from the MEDLINE database. METHODS We retrospectively analyzed the reinterventions for type Ia endoleak and migration after elective infrarenal EVAS at our institution. We collected preoperative, intraoperative, and follow-up data. Open and endovascular techniques are described. Overall survival, aortic-related mortality, and the technical success rate (rate of exclusion of endoleaks) with endovascular techniques were the primary outcomes. RESULTS We performed 101 infrarenal elective EVAS procedures from 2013 to 2018. Of the 101 patients, 20 (19.8%) had required reintervention for proximal sealing failure. The indications were type Ia (Is2, Is3) endoleak, migration >5 mm, sac expansion >5 mm, and secondary rupture. Of the 20 patients, 6 (30%) were treated with endovascular techniques-2 with a chimney Nellix-in-Nellix application and 4 with proximal relining with a covered stent. The remaining 14 patients (70%) were treated with late open conversion (OC). The average time from EVAS to reintervention was 36.1 months (range, 3-65 months). Six patients (30%) had undergone OC in an emergent setting because of secondary rupture. The technical success rate for the patients treated with endovascular reinterventions was 100%. The 30-day mortality was 20% (4 of 20), all emergent cases (four of six emergent repairs; 67%). The overall survival for the 20 patients was 75% (n = 15) at a mean follow-up of 15.1 months (range, 2-47 months). One patient had died after 7 months of non-aortic-related causes. CONCLUSIONS The high reintervention rate of the Nellix graft mandates careful evaluation for its further use with the revised instructions for use, and it should not be used off-label. OC remains the strategy of choice when managing Nellix proximal sealing failures in fit patients. Chimney Nellix-in-Nellix application and transcatheter embolization are feasible alternative techniques. Proximal relining also appears to be an effective alternative to more complex interventions, although it requires further studies for validation.
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Affiliation(s)
- Lorenzo Mortola
- Vascular and Endovascular Surgery Unit, University Hospital of Novara, Novara, Italy.
| | - Emanuele Ferrero
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Simone Quaglino
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Michelangelo Ferri
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Andrea Viazzo
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Paola Manzo
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Andrea Gaggiano
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
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16
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A Canadian multicenter experience describing outcomes after endovascular abdominal aortic aneurysm repair stent graft explantation. J Vasc Surg 2021; 74:720-728.e1. [PMID: 33600929 DOI: 10.1016/j.jvs.2021.01.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 01/06/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Most studies describing the outcomes after endovascular abdominal aortic aneurysm repair (EVAR) explantation have been from single, high-volume, centers. We performed a multicenter cross-Canadian study of outcomes after EVAR stent graft explantation. Our objectives were to describe the outcomes after late open conversion and EVAR graft explantation at various Canadian centers and the techniques and outcomes stratified by the indication for explant. METHODS The Canadian Vascular Surgery Research Group performed a retrospective multicenter study of all cases of EVAR graft explantation at participating centers from 2003 to 2018. Data were collected using a standardized, secure, online platform (RedCap [Research Electronic Data Capture]). Univariate statistical analysis was used to compare the techniques and outcomes stratified the indication for graft explantation. RESULTS Patient data from 111 EVAR explants collected from 13 participating centers were analyzed. The mean age at explantation was 74 years, the average aneurysm size was 7.5 cm, and 28% had had at least one instructions for use violation at EVAR. The average time between EVAR and explantation was 42.5 months. The most common indication for explantation was endoleak (n = 66; type Ia, 46; type Ib, 2; type II, 9; type III, 2; type V, 7), followed by infection in 20 patients; rupture in 18 patients (due to type Ia endoleak in 10 patients, type Ib in 1, type II in 1, type III in 2, and type V in 1), and graft thrombosis in 7 patients. The overall 30-day mortality was 11%, and 45% of the patients had experienced at least one major perioperative complication. Mortality was significantly greater for patients with rupture (33.3%) and those with infection (15%) compared with patients undergoing elective explantation for endoleak (4.5%; P = .003). The average center volume during the previous 15 years was 8 cases with a wide range (2-19 cases). A trend was seen toward greater mortality for patients treated at centers with fewer than eight cases compared with those with eight or more cases (19% vs 9%). However, the difference did not reach statistical significance (P = .23). Overall, 41% of patients had undergone at least one attempt at endovascular salvage before explantation, with the highest proportion among patients who had undergone EVAR explantation for endoleak (51%). Only 22% of patients with rupture had undergone an attempt at endovascular salvage before explantation. CONCLUSIONS The performance of EVAR graft explantation has increasing in Canada. Patients who had undergone elective explantation for endoleak had lower mortality than those treated for either infection or rupture. Thus, patients with an indication for explanation should be offered surgery before symptoms or rupture has occurred. A trend was seen toward greater mortality for patients treated at centers with lower volumes.
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17
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Mathlouthi A, Guajardo I, Al-Nouri O, Malas M, Barleben A. Prophylactic Aneurysm Embolization during EVAR Is Safe, Improves Sac Regression and Decreases the Incidence of Type II Endoleak. Ann Vasc Surg 2021; 74:36-41. [PMID: 33549781 DOI: 10.1016/j.avsg.2020.12.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 12/16/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Clinically significant endoleaks remain costly, time-consuming, morbid and even mortal following endovascular aneurysm repair (EVAR). Perigraft arterial sac embolization (PASE) has been utilized to treat type II endoleaks (T2EL) diagnosed at the time of EVAR or after repair. Our objective was to analyze the safety and efficacy of prophylactic PASE on the incidence of T2EL and aneurysm sac regression in patients undergoing EVAR. METHODS We performed a retrospective review of prospectively maintained databases from the University of California San Diego and the San Diego Veterans Affairs hospitals between 2015 and 2019. Prophylactic PASE (pPASE) was performed at the time of EVAR with thrombin, contrast and gelfoam liquid embolic aneurysm treatment as previously described. We evaluated technical success, freedom from T2EL, freedom from reintervention, from sac expansion, from type I/III EL, from all-cause mortality (ACM), from aneurysm-related mortality and from non-target embolization (NTE). RESULTS A total of 44 patients were included in the study. Technical success was 100% and no NTE was observed. The average duration of follow-up was 14 ± 11months. In those treated and followed by CT scan, 100% of patients' aneurysms halted their growth following PASE, while 65.9% demonstrated sac regression. Mean aneurysm sac diameter decreased by 9 mm (95% CI 7-12). At 3 years, freedom from T2EL was 87.1%. Presence of T2EL did not result in aneurysm expansion during the follow-up period and thus did not require reintervention in any of these patients. Freedom from re-intervention was 83.2% for Type Ib EL and limb occlusion and all procedures were determined to be successful at the time of completion. No aneurysm-related deaths occurred during the follow-up. CONCLUSIONS PASE proves to be an effective tool in sac management for prophylaxis of endoleak and maximizing sac regression in EVAR. It is safe, effective and durable when employed in this manner in the short and medium-term and was associated with low rates of T2ELs and reinterventions and a 100% freedom from sac expansion. Further analysis is required to evaluate the long-term outcomes of this adjunctive procedure in EVAR.
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Affiliation(s)
- Asma Mathlouthi
- Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Isabella Guajardo
- Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Omar Al-Nouri
- Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Mahmoud Malas
- Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Andrew Barleben
- Department of Surgery, University of California, San Diego, La Jolla, CA.
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18
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Acute limb ischemia due to endograft migration. ANGIOLOGIA 2021. [DOI: 10.20960/angiologia.00287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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19
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Moulakakis KG, Lazaris AM, Kakisis JD, Sfyroeras GS, Theocharopoulos G, Panagiotopoulos AI, Krinos N, Geroulakos G. Aortic Rupture during Endovascular Aneurysm Repair. Report of Our Experience and Review of the Literature. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 8:98-103. [PMID: 33307589 PMCID: PMC7732566 DOI: 10.1055/s-0040-1714123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background
Aortic neck wall rupture during endovascular repair of abdominal aortic aneurysms (EVAR) is an underreported potentially fatal complication. Only a few cases have been reported. The main cause of this complication is repeated attempts at balloon inflation or overdilation to treat an intraoperative Type 1a endoleak. We report three cases complicated by procedure-related aortic neck wall rupture during EVAR. We also review the literature regarding the causes and outcomes of this complication.
Methods
Medical records of all patients undergoing EVAR between January 2009 and March 2019 were retrospectively reviewed.
Results
Overall, 824 EVAR procedures were performed, and rupture of the aortic neck wall was observed in three patients. In all cases, a Type 1a endoleak was observed and, in all cases, repeated ballooning attempts had been performed to resolve the endoleaks. In all cases, conversion to open repair was performed and all patients survived.
Conclusion
In cases of Type 1a endoleak, a maximum of two ballooning attempts should be performed even if a Type 1a endoleak persists. In case of intraoperative aortic neck wall rupture, control of the hemorrhage should be achieved immediately by advancing the balloon above the site of rupture. Emergency surgical conversion in case of hemodynamic stability is the first choice. According to the literature, emergency surgical conversion, especially in cases of endograft with suprarenal fixation, is associated with significant morbidity and mortality rates, mainly due to hemorrhage and to the length of the procedure required to repair the aortic neck wall injury.
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Affiliation(s)
- Konstantinos G Moulakakis
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece
| | - Andreas M Lazaris
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece
| | - John D Kakisis
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece
| | - George S Sfyroeras
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece
| | - George Theocharopoulos
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece
| | - Andreas I Panagiotopoulos
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece
| | - Nikolas Krinos
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece
| | - George Geroulakos
- Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece
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20
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Chung BH, Heo SH, Park YJ, Kim DI, Kim DK, Kim YW. Strategy to avoid open surgical conversion after endovascular aortic aneurysm repair for patients with infrarenal abdominal aortic aneurysm. Ann Surg Treat Res 2020; 99:344-351. [PMID: 33304862 PMCID: PMC7704275 DOI: 10.4174/astr.2020.99.6.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 08/11/2020] [Accepted: 09/17/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose Open surgical conversion (OSC) is the last treatment option for patients with endovascular aneurysm repair (EVAR)failure. We investigated the underlying causes of EVAR failure requiring OSC and attempted to determine strategies to avoid OSC after EVAR. Methods We retrospectively reviewed the database of patients who underwent OSC after EVAR from 2005 to 2018 in a single institution. Twenty-six OSCs were performed in 24 patients (median age, 74.5 years; 79.2% of males) who had undergone standard EVAR. We investigated pre-, intra-, and postoperative computed tomography or angiographic images and outcomes of the OSCs. Results Two main indications for OSC were persistent endoleak (50.0%) and endograft infection (EI) (38.5%). All 13 patients who underwent OSC due to endoleaks received EVAR outside of indications for use. Among 10 patients who underwent OSC due to EI, we found overlooked infection sources in 7 (70.0%) at the time of EVAR or during the surveillance period. OSC was performed at a median of 31.8 months (interquartile range, 9.4-69.8) after EVAR as an emergency (15.4%) or elective (84.6%) surgery. Aortic endograft was removed in 84.6% of cases (totally, 57.7%; partially, 26.9%), whereas it was preserved in 4 cases (15.4%). After 26 OSCs, 2 early deaths (7.7%) and 2 aortoenteric fistulae (7.7%) developed as major complications. Conclusion OSC after EVAR was associated with relatively higher perioperative morbidity and mortality. To avoid OSC after EVAR, we recommend careful assessment of coexisting infection sources and avoidance of EVAR for patients with especially unfavorable anatomy for EVAR, particularly the in proximal neck.
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Affiliation(s)
- Byeoung-Hoon Chung
- Department of Surgery, Jeonbuk National University Hospital, Jeonju, Korea
| | - Seon-Hee Heo
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Cardiac and Vascular Center, Samsung Medical Center, Seoul, Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Cardiac and Vascular Center, Samsung Medical Center, Seoul, Korea
| | - Dong-Ik Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Cardiac and Vascular Center, Samsung Medical Center, Seoul, Korea
| | - Duk-Kyoung Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Cardiac and Vascular Center, Samsung Medical Center, Seoul, Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Department of Surgery, Kangbuk Samsung Hospital, Seoul, Korea
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21
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Salem KM, Singh MJ. EVAR: Open Surgical Repair Options for Persistent Type Ia Endoleaks. Semin Intervent Radiol 2020; 37:377-381. [PMID: 33041483 DOI: 10.1055/s-0040-1715867] [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: 10/23/2022]
Abstract
Abdominal aortic aneurysm (AAA) is a disease of the elderly which may result in aneurysm rupture if not treated in a timely manner. The incidence of AAA has increased in part due to patient and physician education, ultrasound screening, and liberal use of computed tomography imaging in conjunction with an aging population. Endovascular aneurysm repair has become the preferred treatment for surgeons and interventionalists. When endografts are placed outside of device-specific instructions for use, the risk of endoleak development is significantly increased. Open surgical repair of Type Ia endoleaks is recommended when endovascular options have been exhausted. Open surgical repair of Type Ia endoleaks provides acceptable perioperative morbidity and mortality rates, long-term durability, and low reintervention rates when performed in the elective setting.
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Affiliation(s)
- Karim M Salem
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael J Singh
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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22
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Marone EM, Rinaldi LF, Lovotti M, Palmieri P. Partial Endograft Removal Preserves the Aortic Walls During Delayed Open Conversions of Endovascular Aortic Repair. Ann Vasc Surg 2020; 67:546-552. [DOI: 10.1016/j.avsg.2020.02.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 01/27/2020] [Accepted: 02/16/2020] [Indexed: 11/16/2022]
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23
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Barleben A, Quinones-Baldrich W, Mogannam A, Archie M, Lane JS, Malas M. Midterm evaluation of perigraft arterial sac embolization in endovascular aneurysm repair. J Vasc Surg 2020; 72:1960-1967. [PMID: 32471739 DOI: 10.1016/j.jvs.2020.01.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 01/22/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Management of clinically significant endoleaks (ELs) remains costly, time-consuming, and morbid. Unresolved ELs can result in rupture and mortality after endovascular aneurysm repair (EVAR). Perigraft arterial sac embolization (PASE) has been used to treat ELs diagnosed at the time of EVAR or during surveillance. METHODS A retrospective review of prospectively maintained databases was conducted. The databases were compiled from two institutions between 2006 and 2016. PASE was performed for type I, type II, or type III EL with a thrombin, contrast medium, and Gelfoam (Pfizer, New York, NY) slurry prepared as previously described. PASE was administered either at the time of EVAR (primary) or during surveillance (secondary). Safety end points included nontarget embolization, defined as neurologic or enteric clinical sequelae from lumbar artery or visceral artery embolization, allergic reaction, peripheral embolization, or rupture. Efficacy end points included successful resolution of EL and cessation of aneurysm sac growth on computed tomography (CT) scans with contrast enhancement. RESULTS A total of 66 patients included in the study were treated with PASE. Primary PASE was performed in 38 patients (58%) and secondary in 28 (42%). Within the total cohort, the average clinical and CT scan follow-up was 1.7 years (0.1-11.6 years). Four patients required open repair for residual high-pressure ELs (one type IIIB and three type I; 6%). Of the 95% of patients who did not require open conversion, aneurysm growth did not occur during the follow-up period. In the overall cohort, PASE was successful in 88% of type I EL and 73% of patients with type II EL. There was no evidence of recanalization after thrombosis of culprit vessel for EL. No patients suffered nontarget embolization, spinal ischemia, allergic reaction, post-EVAR rupture, or colonic ischemia. CONCLUSIONS Primary and secondary PASE proved to be a safe, effective, and durable tool in sac management in conjunction with EVAR. Treating ELs during or after EVAR with PASE has minimized the incidence of EL on CT scan and halted aneurysm growth in our cohort. Further studies are needed to confirm the long-term durability of PASE in reducing secondary interventions after EVAR.
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Affiliation(s)
- Andrew Barleben
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, Calif.
| | - William Quinones-Baldrich
- Division of Vascular and Endovaascular Surgery, Department of Surgery, University of California, Los Angeles, Calif
| | - Abid Mogannam
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, Calif
| | - Meena Archie
- Division of Vascular and Endovaascular Surgery, Department of Surgery, University of California, Los Angeles, Calif
| | - John S Lane
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, Calif
| | - Mahmoud Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, Calif
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Chastant R, Canaud L, Ozdemir BA, Aubas P, Molinari N, Picard E, Branchereau P, Marty-Ané CH, Alric P. Elective late open conversion after endovascular aneurysm repair is associated with comparable outcomes to primary open repair of abdominal aortic aneurysms. J Vasc Surg 2020; 73:502-509.e1. [PMID: 32473342 DOI: 10.1016/j.jvs.2020.05.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 05/06/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Three of four patients with infrarenal abdominal aortic aneurysm are now treated with endovascular aneurysm repair (EVAR). The incidence of secondary procedures and surgical conversions is increasing for a population theoretically unfit for open surgery. The indications and outcomes of late open surgical conversions after EVAR in a high-volume tertiary vascular unit are reported. METHODS This retrospective single-center study includes all patients who underwent a late open conversion between January 1996 and July 2018. Data were collected from records on patient demographics, operative indications, surgical strategy, perioperative outcomes, and medium-term survival. RESULTS Sixty-two consecutive patients (88.7% male) with a mean age of 77.5 years are included. The median duration since index EVAR was 38.5 months; 65% of stent grafts requiring late open conversion had suprarenal fixation. Indications included 22.6% type IA, 16.1% type IB, and 45.2% type II endoleaks; 12.9% graft thrombosis; and 14.5% endoprosthesis infection. Complete endograft explantation was performed in 37.1% of patients and a partial explantation in 54.8%, whereas 8.1% of stent grafts were wholly preserved in situ. Overall 30-day mortality was 12.9% (n = 8) in the cohort and 2.7% for elective patients. The all-cause morbidity rate was 40.1%, and the median length of hospital stay was 9 days. After follow-up of 28.4 months (range, 1.8-187.3 months), all-cause survival was 58.8%. Avoidance of aortic clamping (P = .006) and elective procedures (P = .019) were associated with a significant reduction in the length of hospital stay. Moreover, the 30-day mortality (P = .002), occurrence of postoperative renal dysfunction (P = .004), and intestinal ischemia (P = .017) were increased in the emergency setting. Excluding cases with rupture or infection, survival estimates were 97%, 97%, and 71% at 1 year, 2 years, and 5 years, respectively. CONCLUSIONS Technically more complex than primary open surgery, late open conversion is a procedure that generates an acceptable perioperative risk when it is performed in a high-volume aortic surgical center. Elective open conversion is associated with excellent early and late outcomes. Endograft preservation strategies decrease perioperative morbidity.
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Affiliation(s)
- Robin Chastant
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.
| | - Ludovic Canaud
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Baris Ata Ozdemir
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France; Vascular and Endovascular Department, North Bristol NHS Trust and University of Bristol, Bristol, United Kingdom
| | - Pierre Aubas
- Department of Medical Information, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Nicolas Molinari
- Department of Medical Information, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Eric Picard
- Department of Vascular and Thoracic Surgery, Caremeau Hospital, Nimes, France
| | - Pascal Branchereau
- Department of Vascular and Thoracic Surgery, Caremeau Hospital, Nimes, France
| | - Charles-Henri Marty-Ané
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Pierre Alric
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
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25
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Galanakis N, Kontopodis N, Tavlas E, Tsetis D, Ioannou CV. Does a previous aortic endograft confer any protective effect during abdominal aortic aneurysm rupture? Systematic review and meta-analysis of comparative studies. Vascular 2020; 28:241-250. [PMID: 31937207 DOI: 10.1177/1708538119896464] [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: 11/15/2022]
Abstract
OBJECTIVES Whether prior endovascular aneurysm repair confers a protective effect in patients with ruptured abdominal aortic aneurysm (rAAA) is not known. We aimed to systematically review and compare the outcomes of rAAA in patients with and without prior endovascular aneurysm repair. METHODS We performed a systematic review that conformed to the Preferred Reporting Items for Systematic Reviews and Meta-analysis. We selected studies comparing the outcomes in patients with rAAA after prior endovascular aneurysm repair (group 1) and those with de novo rAAAs (group 2). We conducted a proportion meta-analysis of perioperative mortality and obtained summary estimates of odds ratios (ORs) and 95% confidence intervals (CIs) using random-effects models. RESULTS We included four studies (retrospective observational studies) in quantitative synthesis reporting a total of 719 patients (group 1 (89) group 2 (630)). The perioperative mortality in groups 1 and 2 was 30.4% and 41%, respectively, and there was no statistical significant difference between the groups (OR 0.66, 95% CI 0.30-1.43, P = 0.29, I2=58%). However, patients presenting with rAAA following previous endovascular aneurysm repair were more hemodynamically stable (OR 0.33, 95% CI 0.12-0.90, P = 0.03, I2=74%). The choice between endovascular or open surgery treatment in group 1 did not affect the perioperative mortality (OR 1.12, 95% CI 0.41-3.04 P = 0.82, I2=0%). Endoleak types I and III were the main causes of rAAA in group 1. CONCLUSIONS Perioperative mortality was similar for rAAA either de novo or after prior endovascular aneurysm repair. However, ruptures in patients with prior endovascular aneurysm repair presented hemodynamically more stable.
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Affiliation(s)
- Nikolaos Galanakis
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, Heraklion, Greece
| | - Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, Heraklion, Greece
| | - Emmanouil Tavlas
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, Heraklion, Greece
| | - Dimitrios Tsetis
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, Heraklion, Greece
| | - Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, Heraklion, Greece
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Abstract
A hybrid suite is an operating theater with imaging equipment equivalent to that used in an angiography suite with computed tomography (CT) and magnetic resonance imaging (MRI). They are often situated outside the operating room area and typically serve as multifunctional rooms designed to support a variety of catheter-based endovascular procedures and open surgery to be performed in the same location. The possibility to perform these in the same location facilitates the combination of both approaches to so-called hybrid procedures. Typical clinical applications of hybrid suites are cardiac, thoracic and vascular surgery, neurosurgery and neuroradiology, as well as orthopedics and traumatology. Transcatheter aortic valve implantation (TAVI) is significantly less invasive than a classical approach by open surgery. Patients older than 75 years with relevant comorbidities benefit most from the minimally invasive interventional approach. There has been a paradigm shift in the management of vascular diseases from open surgical repair to new percutaneous endovascular interventions with good early outcomes. Of particular interest in this context is the ability to block the part of the aorta proximal to the aneurysm with a catheter-based dilatation balloon. Progress in image fusion technology and intraoperative navigation has led to an increased acceptance of hybrid suites in orthopedics and traumatology. The complex care of high-risk patients most often outside the operating theater area is a challenge for the anesthesia team. This demands meticulous planning on behalf of the anesthesiologist to ensure an appropriate and safe strategy for anesthesia, intraoperative monitoring, vascular access and the need for additional equipment. A thorough understanding of the complexity of procedures is vital and a series of questions must be addressed: what is needed to safely administer anesthesia in this environment? What additional resources would be needed for an emergency situation? Is the patient being kept safe from radiation hazards? Moreover, logistics may become an issue as the hybrid suite is most often delocalized. In addition, many procedures realized in a hybrid suite require a multidisciplinary approach and therefore teamwork and professional communication are mandatory. Anesthesiologists need to have an integral role in the hybrid suite team, understanding and anticipating the risks for patients and leading the organization of workflow. The challenge in anesthesia is to ensure that when patients are taken to these complex environments the resources available enable high standards of care to be provided. With future developments in imaging technology combined with more powerful hardware and software, a far greater integration of all these imaging and navigation technologies will be seen in future operating rooms. Finally, patients are becoming more aware of medical developments via the world wide web and increasingly request what they consider to be state of the art treatment.
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Affiliation(s)
- T Fuchs-Buder
- Klinik für Anästhesie und Intensivmedizin, Universitätsklinikum Nancy, Nancy, Frankreich. .,Département d'Anesthésie-Réanimation, Rue du Morvan, 54511, Vandoeuvre-les-Nancy, Frankreich.
| | - N Settembre
- Klinik für Gefäßchirurgie, Universitätsklinikum Nancy, Nancy, Frankreich
| | - D Schmartz
- Klinik für Anästhesie, Universitätsklinikum Brugmann, Brüssel, Belgien
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Stilo F, Montelione N, Catanese V, Vigliotti RC, Spinelli F. Minimally Invasive Open Conversion for Late EVAR Failure. Ann Vasc Surg 2019; 63:92-98. [PMID: 31626941 DOI: 10.1016/j.avsg.2019.08.087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/02/2019] [Accepted: 08/02/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE With the increasing use of endovascular aortic aneurysm repair (EVAR), open repair after aortic stent grafting is of growing interest. The surgical conversion treatment may be a very challenging process with high mortality and in-hospital complication rates. The aim of this article is to present our experience in patients with EVAR failure treated by minimally invasive open conversion (MOC) and its technical aspects. METHODS A retrospective study was conducted on a prospectively compiled computerized database of consecutive patients treated by MOC at our institution between May 2014 and June 2018. Indications for treatment were endoleaks with sac growth at least >5 mm in the last 6 months and failure of previous endovascular tentative for aneurysm sealing. Demographics of the patients, reason for conversion, previous endovascular procedures, surgical outcomes, and survival were reviewed. MOC was performed by a small abdominal incision, infrarenal clamping, and partial explantation of the endograft in all patients. RESULTS A total of 10 patients were treated during the study period. The mean interval to MOC after EVAR was 45.1 months (range, 14-128). Indications for MOC included type Ia endoleak in three patients (30%), persistent type II EL in four (40%), and type III EL in one patient (10%), indeterminate or type V EL in two (20%). At 30 days, no deaths or reinterventions were reported, and major complication rate was 10% (one postoperative pneumonia). At mean follow-up of 22.9 ± 15.9 months, no reinterventions were described. Death rate was (20%) with one aneurysm-related death (10%) for graft infection 32 months after MOC and one (10%) cardiac event at 18 months. CONCLUSIONS Despite the potential high risk of open conversion, MOC appears to be a safe surgical solution for EVAR failure. This potentially challenging operation may be improved with minimally invasive techniques that are presented.
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Affiliation(s)
- Francesco Stilo
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy
| | - Nunzio Montelione
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy.
| | - Vincenzo Catanese
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy; Division of Vascular Surgery, Department of Medical, Surgical, and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Rossella C Vigliotti
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy; Division of Vascular Surgery, Department of Medical, Surgical, and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Francesco Spinelli
- Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy
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Perini P, Bianchini Massoni C, Mariani E, D'ospina RM, Rossi G, Carli AG, Bramucci A, Azzarone M, Freyrie A. Late open conversions after failed EVAR. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2019. [DOI: 10.23736/s1824-4777.19.01419-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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29
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Goudeketting SR, Fung Kon Jin PP, Ünlü Ç, de Vries JPP. Systematic review and meta-analysis of elective and urgent late open conversion after failed endovascular aneurysm repair. J Vasc Surg 2019; 70:615-628.e7. [DOI: 10.1016/j.jvs.2018.11.022] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/19/2018] [Indexed: 12/18/2022]
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30
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de Jesus-Silva SG, de Oliveira VR, de Moraes-Silva MA, Krupa AE, Cardoso RS. Risk factors and short and medium-term survival after open and endovascular repair of abdominal aortic aneurysms. J Vasc Bras 2019; 17:201-207. [PMID: 30643505 PMCID: PMC6326136 DOI: 10.1590/1677-5449.011717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Infrarenal abdominal aortic aneurysms (AAA) are responsible for high rates of rupture-associated morbidity and mortality and can be treated by open or endovascular surgery. Objectives To analyze risk factors and survival associated with surgical and endovascular AAA treatment methods. Methods A retrospective, longitudinal study involving 41 patients who underwent endovascular or open AAA repair, whether elective or emergency, over a 48-month period, with analysis of preoperative comorbidities, 30-day and 1-year survival, in-hospital mortality, length of hospital stay, transfusion of blood products, duration of surgery, and development of acute kidney failure. Inferential statistics and survival analysis considered a 95% CI and p < 0.05 as significant. Results Twelve of the 41 patients were treated with open surgery and 29 with endovascular techniques. The majority were male (75%), with an average age of 71 (range: 56 – 90 years). There were no differences in demographic or risk factors between the groups. Overall survival rates for open and endovascular repair were different for both 30 days (37 vs. 72%, p = 0.01) and 360 days (37 vs. 67%, p = 0.01). However, survival rates in elective cases were similar at 30 days (71 vs. 76%, p = 0.44) and 360 days (both 71%, p = 0.34). Endovascular repair showed shorter length of hospital stay (3.0 vs. 4.4 days; p = 0.02) and duration of surgery (111 vs. 163 min; p < 0.01) compared to open repair. Conclusions There was no difference in short- or medium-term survival of AAA patients treated electively with endovascular or open surgery. Hospital stays and duration of surgery were both shorter with minimally invasive treatment.
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Affiliation(s)
| | | | | | - Arturo Eduardo Krupa
- Hospital de Clínicas de Itajubá - HC, Serviço de Cirurgia Vascular e Endovascular, Itajubá, MG, Brasil
| | - Rodolfo Souza Cardoso
- Hospital de Clínicas de Itajubá - HC, Serviço de Cirurgia Vascular e Endovascular, Itajubá, MG, Brasil
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31
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Joo HC, Lee SH, Chang BC, Lee S, Yoo KJ, Youn YN. Late open conversion after endovascular abdominal aortic repair: a 20-year experience. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019. [DOI: 10.23736/s0021-9509.18.10173-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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32
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Mohapatra A, Robinson D, Malak O, Madigan MC, Avgerinos ED, Chaer RA, Singh MJ, Makaroun MS. Increasing use of open conversion for late complications after endovascular aortic aneurysm repair. J Vasc Surg 2018; 69:1766-1775. [PMID: 30583895 DOI: 10.1016/j.jvs.2018.09.049] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 09/29/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Open procedures are often required for late complications after endovascular aneurysm repair (EVAR). Our aim was to describe the indications for open interventions and their postoperative outcomes and to specifically examine our experience with limited conversions in which problem endoleaks are targeted without endograft explantation. METHODS We reviewed patients from 2002 to 2017 who underwent any surgical abdominal aortic operation after a previous EVAR. Baseline characteristics, preoperative imaging, procedural details, and postoperative outcomes were reviewed. The primary end point was 30-day mortality. RESULTS There were 102 patients who underwent open conversion 3.8 ± 3.1 years after EVAR. The numbers increased significantly in recent years, with 18 cases performed in 2016; 48.5% of patients had undergone 1.9 ± 1.0 prior endovascular interventions. The indication for surgical conversion was an endoleak in 85 patients and infection in 15. One patient had a limb occlusion and another a proximal aneurysm. The 30-day mortality was 6.2% in 65 patients treated electively for endoleak but higher in 20 ruptures (40.0%) and 15 infections (40.0%). In a multivariate logistic regression model, independent predictors of 30-day mortality were rupture (odds ratio [OR], 6.70; 95% confidence interval [CI], 1.75-25.60; P = .005), endograft infection (OR, 8.48; 95% CI, 1.99-36.20; P = .004), and use of a supraceliac clamp (OR, 4.80; 95% CI, 1.47-15.66; P = .009). Transient acute kidney injury (12.8%) and prolonged intubation (11.8%) were the most common postoperative complications. In 65 patients treated for endoleak without rupture, 37 underwent endograft explantation, whereas 28 had a graft-preserving intervention (branch vessel ligation for type II endoleak in 26, external banding of the aneurysm neck for type IA endoleak in 8). Mortality was 8.1% when the endograft was explanted and 3.6% when it was not (P = .63). During 3.0 ± 3.5 years of follow-up, there was one reintervention after endograft explantation (for rupture secondary to type IB endoleak) and two reinterventions after graft preservation (for a new type IA endoleak and a new type II endoleak). Survival was 87.4% at 1 year and 70.9% at 5 years. CONCLUSIONS Open conversion is playing an increasing role in the management of late EVAR complications. Endoleaks treated electively by open conversion are reasonably safe and show good midterm durability, even with graft-preserving interventions that avoid endograft explantation.
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Affiliation(s)
- Abhisekh Mohapatra
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Darve Robinson
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Othman Malak
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michael C Madigan
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Efthimios D Avgerinos
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Rabih A Chaer
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michael J Singh
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michel S Makaroun
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
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Law Y, Chan YC, Cheng SW. Delayed open conversion after endovascular aortic repair. Asian Cardiovasc Thorac Ann 2018; 27:80-86. [PMID: 30563352 DOI: 10.1177/0218492318820195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM We present the clinical outcomes of patients who underwent delayed (>30 days) open surgical repair after endovascular aortic aneurysm repair. METHODS All patients receiving delayed open repair of infrarenal and juxtarenal aortic aneurysms after endovascular repair from July 2001 to December 2017 were retrospectively reviewed. Patients' baseline characteristics, indications for delayed open conversion, and time between endovascular repair and open conversion are described. Early outcomes included operative approach, morbidity, and mortality. Midterm outcomes included survival. RESULTS Twenty-two (3.3%) of 667 patients with prior infrarenal endovascular aortic aneurysm repair had delayed open conversion (20 elective and 2 emergency). The time from endovascular repair to open conversion was 60 ± 36 months. The indications were 6 (27%) type Ia endoleaks, 6 (27%) type II endoleaks with enlarging sac size, 2 (9%) endotensions, 7 (32%) unknown types of endoleak, and 1 (5%) graft infection. The 7 minutes unknown endoleaks were confirmed as lumbar leaks in 4 cases and fabric leaks in 3. Operative time was 222 ± 48 min with blood loss of 2211 ± 2057 mL. Hospital stay after conversion was 12 ± 8 days. There was no 30-day mortality. Estimated survival rates were 96%, 91%, 86%, 79% and 57% at 1, 2, 3, 4, and 5 years postoperatively. CONCLUSION Delayed conversion to open surgery after endovascular aortic aneurysm repair by endograft explantation appears to be safe with good short- and mid-term outcomes. With careful preoperative assessment, open conversion remained a realistic and viable option in patients with failed endovascular treatment.
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Affiliation(s)
- Y Law
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Y C Chan
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - S W Cheng
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
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Rasheed K, Stoner MC. Aortic endograft explantation in the setting of prior heterotopic renal allograft. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2018; 4:275-277. [PMID: 30547145 PMCID: PMC6282867 DOI: 10.1016/j.jvscit.2018.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/17/2018] [Indexed: 11/29/2022]
Abstract
It is rare to require explantation of an aortic endograft placed for endovascular aneurysm repair (EVAR). Sustained aneurysm growth in the setting of prior endovascular repair, despite secondary interventions and use of adjuncts, is the most common cause of EVAR explantation. An infected endograft and aneurysm rupture after EVAR represent more urgent or emergent indications for explantation and have a significantly greater associated morbidity and mortality. This case of endograft explantation is of even greater complexity, given the patient's specific history of aneurysm repair in the concomitant setting of a functioning renal allograft.
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Affiliation(s)
- Khurram Rasheed
- Division of Vascular Surgery, University of Rochester, Rochester, NY
| | - Michael C Stoner
- Division of Vascular Surgery, University of Rochester, Rochester, NY
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Wee I, Marjot T, Patel K, Bhrugubanda V, Choong AMTL. Laparoscopic ligation of Type II endoleaks following endovascular aneurysm repair: A systematic review. Vascular 2018; 26:657-669. [PMID: 29966486 DOI: 10.1177/1708538118773611] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The clinical significance of Type II endoleak remains contentious; the strategies used for its management have continued to expand. We systematically review the literature and comprehensively appraise the effectiveness of laparoscopic intervention in the management of this common complication. METHODS A systematic search was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines on MEDLINE, EMBASE and Cochrane Library for relevant articles reporting laparoscopic surgery of Type II endoleak post-endovascular aortic repair. RESULTS Thirteen studies representing 40 patients were investigated. Mean age was 72.7 years, and proportion of males was 90.0%. All patients were American Society of Anesthesiologists grade II and above and underwent standard infrarenal endovascular aneurysm repair. The mean duration of operation was 130.2 min, with a mean blood loss across of 173.8 mL. The overall technical success rate was 90% (27/30). Two patients required reoperation within 24 h, with further lumbar ligations that were successful. One other patient required conversion to open surgery due to significant bleeding at the dorsal aorta. The perioperative and 30-day mortality rate was 2.5% (1/40). The mean length of hospital stay was 3.7 days (range 1 to 10 days). The mean length of follow-up was 36.7 months (range 3 to 103.2 months), where the rate of recurrence was 22.5% (9/40). CONCLUSIONS Laparoscopic ligation of feeding vessels causing Type II endoleak is potentially an alternative treatment after failed standard endovascular embolization, particularly in select centres with necessary resources and capabilities.
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Affiliation(s)
- Ian Wee
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore
- 2 Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Thomas Marjot
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore
- 3 Imperial College Healthcare NHS Trust, London, UK
| | - Kirtan Patel
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore
- 4 Southend University Hospital National Health Service Foundation Trust, Essex, UK
| | - Vamsee Bhrugubanda
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore
- 5 Lancashire Teaching Hospitals Trust National Health Service Foundation Trust, Preston, UK
| | - Andrew MTL Choong
- 1 SingVaSC, Singapore Vascular Surgical Collaborative, Singapore, Singapore
- 6 Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore
- 7 Division of Vascular Surgery, National University Heart Centre, Singapore, Singapore
- 8 Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Georgakarakos E, Koutsoumpelis A, Popidis S, Tasopoulou KM, Georgiadis GS. A Complex Case of Synchronous Thoracic and Abdominal Endoleak Repair with Custom-Made Relay NBS Thoracic Stent Graft and Abdominal Open Reconstruction. Ann Vasc Surg 2018; 56:345-349. [PMID: 30496897 DOI: 10.1016/j.avsg.2018.08.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/13/2018] [Accepted: 08/21/2018] [Indexed: 10/27/2022]
Abstract
A 71-year old man with previous thoracic aneurysm endovascular repair and endovascular abdominal aneurysm repair presented with simultaneous type III endoleak from the thoracic components and type Ia endoleak from migration of the abdominal endograft, leading to enlargement of both aneurysms. A custom-made reverse tapered Relay NBS thoracic endograft was used to bridge the thoracic stent grafts. While a low-flow type III endoleak persisted in the immediate postoperative phase, because of incomplete apposition of the new stent graft, further deployment of its nitinol skeleton resulted in resolution of the endoleak at 1-week follow-up. The abdominal aneurysm enlargement was corrected via excision of the central segment of the abdominal endograft, preservation of the distal main body and limbs, and interposition of a short Dacron tube graft.
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Affiliation(s)
- Efstratios Georgakarakos
- Democritus University of Thrace, Department of Vascular Surgery, University Hospital of Alexandroupolis, Alexandroupolis, Greece.
| | - Andreas Koutsoumpelis
- Democritus University of Thrace, Department of Vascular Surgery, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Stefanos Popidis
- Democritus University of Thrace, Department of Vascular Surgery, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Kalliopi-Maria Tasopoulou
- Democritus University of Thrace, Department of Vascular Surgery, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - George S Georgiadis
- Democritus University of Thrace, Department of Vascular Surgery, University Hospital of Alexandroupolis, Alexandroupolis, Greece
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Hofmeister S, Thomas MB, Paulisin J, Mouawad NJ. Endovascular management of ruptured abdominal aortic aneurysms and acute aortic dissections. VASA 2018; 48:35-46. [PMID: 30407131 DOI: 10.1024/0301-1526/a000760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The management of vascular emergencies is dependent on rapid identification and confirmation of the diagnosis with concurrent patient stabilization prior to immediate transfer to the operating suite. A variety of technological advances in diagnostic imaging as well as the advent of minimally invasive endovascular interventions have shifted the contemporary treatment algorithms of such pathologies. This review provides a comprehensive discussion on the current state and future trends in the management of ruptured abdominal aortic aneurysms as well as acute aortic dissections.
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Affiliation(s)
- Stephen Hofmeister
- 1 McLaren Bay Heart & Vascular, McLaren Bay Region, Bay City, Michigan, USA
| | - Matthew B Thomas
- 1 McLaren Bay Heart & Vascular, McLaren Bay Region, Bay City, Michigan, USA
| | - Joseph Paulisin
- 1 McLaren Bay Heart & Vascular, McLaren Bay Region, Bay City, Michigan, USA
| | - Nicolas J Mouawad
- 1 McLaren Bay Heart & Vascular, McLaren Bay Region, Bay City, Michigan, USA
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Meng C, Guo Z, Li D, Li H, Zhou J, Wen D, Luo B. miR-183 and miR-141 in lesion tissues are potential risk factors for poor prognosis in patients with infected abdominal aortic aneurysm. Exp Ther Med 2018; 16:4695-4699. [PMID: 30542422 PMCID: PMC6257808 DOI: 10.3892/etm.2018.6733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 09/04/2018] [Indexed: 12/25/2022] Open
Abstract
The expression levels of micro ribonucleic acid-183 (miR-183) and miR-141 in the lesion tissues of infected abdominal aortic aneurysm (IAAA) and their relationship with prognosis were investigated. Thirty-six patients with IAAA admitted and who underwent vascular surgery in People's Hospital of Shenzhen from June 2003 to June 2013 were selected. Reverse transcription polymerase chain reaction (RT-PCR) was utilized to detect the expression levels of miR-183 and miR-141 in lesion tissues and adjacent tissues 1 cm away from the aneurysm in 36 patients with IAAA. The relationship between the expression levels of miR-183 and miR-141 as well as the clinicopathological features of patients with IAAA were analyzed, and the factors influencing the prognosis of IAAA were analyzed by univariate and multiva-riate analysis. The expression levels of miR-183 and miR-141 were significantly downregulated in the lesions of patients with IAAA, and miR-183 and miR-141 levels in the lesion tissues of the IAAA patients were significantly lower than those in the adjacent tissues (P<0.05). The expression levels of miR-183 and miR-141 were not related to sex, age, history of hypertension, and alcoholism (P>0.05), but they were related to smoking history or aneurysm size (P<0.05). The overall survival rate of patients with IAAA was 41.6% (15/36). The multivariate analysis found that aneurysm size, low expression of miR-183, and low expression of miR-141 were independent factors affecting the prognosis of patients with IAAA. In conclusion, the expression levels of miR-183 and miR-141 in the lesion tissues of IAAA are low, and the lower the expression level is, the worse the prognosis gets. miR-183 and miR-141 can be used as predictors of prognosis in patients with IAAA.
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Affiliation(s)
- Chunying Meng
- Department of Cardiovascular Surgery, Jinan University 2nd Clinical Medicine College People's Hospital of Shenzhen, Shenzhen, Guangdong 518020, P.R. China
| | - Zeheng Guo
- Out-patient Department, Futian District Maternal and Child Health Hospital of Shenzhen City, Shenzhen, Guangdong 518045, P.R. China
| | - Dagang Li
- Department of Cardiovascular Surgery, Jinan University 2nd Clinical Medicine College People's Hospital of Shenzhen, Shenzhen, Guangdong 518020, P.R. China
| | - Hanwei Li
- Department of Cardiovascular Surgery, Jinan University 2nd Clinical Medicine College People's Hospital of Shenzhen, Shenzhen, Guangdong 518020, P.R. China
| | - Jun Zhou
- Department of Cardiovascular Surgery, Jinan University 2nd Clinical Medicine College People's Hospital of Shenzhen, Shenzhen, Guangdong 518020, P.R. China
| | - Dingguo Wen
- Department of Cardiovascular Surgery, Jinan University 2nd Clinical Medicine College People's Hospital of Shenzhen, Shenzhen, Guangdong 518020, P.R. China
| | - Bin Luo
- Department of Cardiovascular Surgery, Jinan University 2nd Clinical Medicine College People's Hospital of Shenzhen, Shenzhen, Guangdong 518020, P.R. China
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Kurç E, Sokullu O, Akansel S, Sargın M. Late open conversion in ruptured abdominal aortic aneurysm after endovascular repair. J Vasc Bras 2018; 17:66-70. [PMID: 29930684 PMCID: PMC5990265 DOI: 10.1590/1677-5449.008017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Despite technological advances, the long-term outcomes of endovascular aortic aneurysm repair (EVAR) are still debatable. Although most endograft failures after EVAR can be corrected with endovascular techniques, open conversion may still be required. A 70-year-old male patient presented at the emergency unit with abdominal pain. Twice, in the third and fourth years after the first repair, a stent graft had been placed over a non-adhesive portion of the stent graft due to type Ia endoleaks. In the most recent admission, a CT scan showed type III endoleak and ruptured aneurysm sac. On this occasion the patient underwent late open conversion. The failure was repaired with total preservation of the main endovascular graft body and interposition of a bifurcated dacron graft. This case demonstrates that lifelong radiographic surveillance should be considered in this subset of patients. Late open conversion following EVAR of ruptured abdominal aortic aneurysms can be performed safely.
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Affiliation(s)
- Erol Kurç
- Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Onur Sokullu
- Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Serdar Akansel
- Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Murat Sargın
- Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
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Ronchey S, Fazzini S, Scali S, Torsello G, Kubilis P, Veith F, Donas KP, Pecoraro F, Mangialardi N. Collected Transatlantic Experience From the PERICLES Registry: Use of Chimney Grafts to Treat Post-EVAR Type Ia Endoleaks Shows Good Midterm Results. J Endovasc Ther 2018; 25:492-498. [DOI: 10.1177/1526602818782941] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: The aim of this retrospective analysis was to evaluate the performance of the chimney (ch) technique in the treatment of type Ia endoleaks after standard endovascular aneurysm repair (EVAR). Methods: Between January 2008 and December 2014, 517 chEVAR procedures were performed in 13 US and European vascular centers (PERICLES registry). Thirty-nine patients (mean age 76.9±7.1 years; 33 men) were treated for persistent type Ia endoleak and had computed tomography angiography or magnetic resonance angiography follow-up at >1 month. Endurant abdominal stent-grafts were used in the 20 cases. Single chimney graft placement was performed in 18 (46%) patients and multiple in 21 (54%). Overall, 70 visceral vessels were targeted for revascularization. Results: Technical success was achieved in 35 (89.7%) cases; 3 persistent type Ia endoleaks and 1 chimney graft occlusion were detected within the first 30 days. Thirty-day mortality was 2.6%. Two other deaths (not aneurysm related) occurred during a mean follow-up of 21.9 months (0.23–71.3). Primary patency of the chimney grafts was 94.3% at 36 months. In a subgroup analysis comparing Endurant to other stent-grafts, no significant differences were observed regarding persistent endoleak [1/20 (5%) vs 2/19 (11%), p=0.6] or reintervention [1/20 (5%) vs 0/19 (0%)]. Conclusion: The present series demonstrates that chEVAR in the treatment of post-EVAR type Ia endoleaks has satisfactory results independent of the abdominal and chimney graft combinations. Midterm results show that chEVAR is an effective method for treating type Ia endoleaks.
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Affiliation(s)
- Sonia Ronchey
- Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy
| | - Stefano Fazzini
- Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy
| | - Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - Giovanni Torsello
- Department of Vascular Surgery, St Franziskus Hospital Münster, Germany
| | - Paul Kubilis
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - Frank Veith
- Cardiovascular Surgery Unit, University Hospital Zurich, Switzerland
- New York University Medical Center, New York, NY, USA
| | | | - Felice Pecoraro
- Cardiovascular Surgery Unit, University Hospital Zurich, Switzerland
- University of Palermo, Vascular Surgery Unit, AOUP “P. Giaccone”, Palermo, Italy
| | - Nicola Mangialardi
- Department of Vascular Surgery, “San Camillo-Forlanini” Hospital, Rome, Italy
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Daye D, Walker TG. Complications of endovascular aneurysm repair of the thoracic and abdominal aorta: evaluation and management. Cardiovasc Diagn Ther 2018; 8:S138-S156. [PMID: 29850426 DOI: 10.21037/cdt.2017.09.17] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In recent decades, endovascular aneurysm repair or endovascular aortic repair (EVAR) has become an acceptable alternative to open surgery for the treatment of thoracic and abdominal aortic aneurysms and other aortic pathologies such as the acute aortic syndromes (e.g., penetrating aortic ulcer, intramural hematoma, dissection). Available data suggest that endovascular repair is associated with lower perioperative 30-day all-cause mortality as well as a significant reduction in perioperative morbidity when compared to open surgery. Additionally, EVAR leads to decreased blood loss, eliminates the need for cross-clamping the aorta and has shorter recovery periods than traditional surgery. It is currently the preferred mode of treatment of thoracic and abdominal aortic aneurysms in a subset of patients who meet certain anatomic criteria conducive to endovascular repair. The main disadvantage of EVAR procedures is the high rate of post-procedural complications that often require secondary re-intervention. As a result, most authorities recommend lifelong imaging surveillance following repair. Available surveillance modalities include conventional radiography, computed tomography, magnetic resonance angiography, ultrasonography, nuclear imaging and conventional angiography, with computed tomography currently considered to be the gold standard for surveillance by most experts. Following endovascular abdominal aortic aneurysm (AAA) repair, the rate of complications is estimated to range between 16% and 30%. The complication rate is higher following thoracic EVAR (TEVAR) and is estimated to be as high as 38%. Common complications include both those related to the endograft device and systemic complications. Device-related complications include endoleaks, endograft migration or collapse, kinking and/or stenosis of an endograft limb and graft infection. Post-procedural systemic complications include end-organ ischemia, cerebrovascular and cardiovascular events and post-implantation syndrome. Secondary re-interventions are required in approximately 19% to 24% of cases following endovascular abdominal and thoracic aortic aneurysm repair respectively. Typically, most secondary reinterventions involve the use of percutaneous techniques such as placement of cuff extension devices, additional endograft components or stents, enhancement of endograft fixation, treatment of certain endoleaks using various embolization techniques and embolic agents and thrombolysis of occluded endograft components. Less commonly, surgical conversion and/or open surgical modification are required. In this article, we provide an overview of the most common complications that may occur following endovascular repair of thoracic and AAAs. We also summarize the current surveillance recommendations for detecting and evaluating these complications and discuss various current secondary re-intervention approaches that may typically be employed for treatment.
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Affiliation(s)
- Dania Daye
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - T Gregory Walker
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Jessula S, Herman CR, Lee M, Lightfoot CB, Casey P. Salvage of bilateral renal artery occlusion after endovascular aneurysm repair with open splenorenal bypass. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2018; 3:163-166. [PMID: 29349409 PMCID: PMC5764852 DOI: 10.1016/j.jvscit.2017.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/01/2017] [Indexed: 11/22/2022]
Abstract
We report renal salvage maneuvers after accidental bilateral renal artery coverage during endovascular aneurysm repair of an infrarenal abdominal aortic aneurysm. A 79-year-old man with an infrarenal abdominal aortic aneurysm was treated with endovascular aneurysm repair. Completion angiography demonstrated coverage of the renal arteries. Several revascularization techniques were attempted, including endograft repositioning and endovascular stenting through the femoral and brachial approach. The patient eventually underwent open splenorenal bypass with a Y Gore-Tex graft (W. L. Gore & Associates, Flagstaff, Ariz). After 3 months, computed tomography showed no evidence of endoleak and patent renal arteries. Renal function was well maintained, and the patient did not require dialysis.
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Affiliation(s)
- Samuel Jessula
- Department of General Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Christine R Herman
- Division of Vascular Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.,Division of Cardiac Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Min Lee
- Division of Vascular Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Christopher B Lightfoot
- Department of Diagnostic and Interventional Radiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Patrick Casey
- Division of Vascular Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Georgakarakos E, Kratimenos T, Koutsoumpelis A, Georgiadis GS. The Bolton Treo endograft for treatment of abdominal aortic aneurysms: just another trimodular platform? Expert Rev Med Devices 2017; 15:5-14. [DOI: 10.1080/17434440.2018.1419864] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Efstratios Georgakarakos
- Department of Vascular Surgery, Democritus University of Thrace, Alexandroupolis, Greece
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Theodoros Kratimenos
- Department of Interventional Radiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Andreas Koutsoumpelis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - George S. Georgiadis
- Department of Vascular Surgery, Democritus University of Thrace, Alexandroupolis, Greece
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Alexandroupolis, Greece
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44
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Perini P, de Troia A, Tecchio T, Azzarone M, Bianchini Massoni C, Salcuni P, Freyrie A. Infrarenal endograft clamping in late open conversions after endovascular abdominal aneurysm repair. J Vasc Surg 2017; 66:1048-1055. [DOI: 10.1016/j.jvs.2017.01.057] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 01/31/2017] [Indexed: 10/19/2022]
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45
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Gemayel G, Verdon G, Murith N, Huber C. Rescue of a Failing Endovascular Infrarenal Aortic Repair Using an Off-The-Shelf Branched Endograft. Ann Vasc Surg 2017; 45:269.e15-269.e18. [PMID: 28739451 DOI: 10.1016/j.avsg.2017.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Proximal aortic dilation following open and endovascular aortic repair (EVAR) is a well-known phenomenon. If severe enough, it may lead to late onset of type Ia endoleak that jeopardizes the proximal seal. METHODS We report the case of a patient previously treated by EVAR for an infrarenal aneurysm who developed a type Ia endoleak after proximal aortic dilation. His aneurysms enlarged to 10 cm mandating a rapid repair without the delay for a custom-made device. RESULTS We successfully used the off-the-shelf thoracic t-Branch graft (Cook, Bloomington, IN) with its 4 branches to treat the dilated aorta and seal the endoleak. CONCLUSION The off-the-shelf t-Branch is a useful option in patient with previous EVAR presenting with proximal aortic dilation and endoleak who cannot wait for a custom-made device.
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Affiliation(s)
- Gino Gemayel
- Cardiovascular Surgery Department, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Gabriel Verdon
- Cardiovascular Surgery Department, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nicolas Murith
- Cardiovascular Surgery Department, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christoph Huber
- Cardiovascular Surgery Department, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Ultee KHJ, Soden PA, Zettervall SL, Darling J, Verhagen HJM, Schermerhorn ML. Conversion from endovascular to open abdominal aortic aneurysm repair. J Vasc Surg 2017; 64:76-82. [PMID: 27345505 DOI: 10.1016/j.jvs.2015.12.055] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 12/22/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Previous studies have found conflicting results regarding the operative risks associated with conversion to open abdominal aortic aneurysm (AAA) repair after failed endovascular treatment (endovascular aneurysm repair [EVAR]). The purpose of this study was to assess the outcome of patients undergoing a conversion, and compare outcomes with standard open AAA repair and EVAR. In addition, we sought out to identify factors associated with conversion. METHODS All patients undergoing a conversion to open repair, and those undergoing standard EVAR and open repair between 2005 and 2013 were included from the National Surgical Quality Improvement Program. Multivariable logistic regression analysis was used to identify factors associated with conversion, and to assess independent perioperative risks associated with conversion compared with standard AAA repair. Subanalysis for factors associated with conversion was performed among patients additionally included in the more detailed targeted vascular module of the National Surgical Quality Improvement Program. RESULTS A total of 32,164 patients were included, with 300 conversions, 7188 standard open repairs, and 24,676 EVARs. Conversion to open repair was associated with a significantly higher 30-day mortality than standard open repair (10.0% vs 4.2%; odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001), and EVAR (10.0% vs 1.7%; OR, 7.2; 95% CI, 4.8-10.9; P < .001). Conversion surgery was additionally followed by an increased occurrence of any complication (OR, 1.5; 95% CI, 1.2-1.9 [open]; OR, 7.8; 95% CI, 6.1-9.9 [EVAR]). Factors associated with conversion were young age (OR, 1.2 per 10 years decrease; 95% CI, 1.1-1.4), female gender (OR, 1.5; 95% CI, 1.2-2.0), and nonwhite race (OR, 1.8; 95% CI, 1.3-2.6). Conversely, body mass index >30 was negatively associated with (OR, 0.7; 95% CI, 0.5-0.9). Among anatomic characteristics captured in the targeted vascular data set (n = 4555), large aneurysm diameter demonstrated to be strongly associated with conversion (OR, 1.1 per 1 cm increase; 95% CI, 1.03-1.1). CONCLUSIONS Conversion to open repair after failed EVAR is associated with substantially increased perioperative morbidity and mortality compared with standard AAA repair. Factors associated with conversion are large diameter of the aneurysm, young age, female gender, and nonwhite race, whereas obesity is inversely related to conversion surgery.
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Affiliation(s)
- Klaas H J Ultee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Jeremy Darling
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
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Reyes Valdivia A, Redondo López S, Aracil Sanus E, Ocaña Guaita J, Gandarias Zúñiga C. Conversión a cirugía abierta, mediante explante endoprotésico, tras intento fallido de tratamiento endovascular, y persistencia de fuga Ia, en aneurisma de aorta abdominal roto. ANGIOLOGIA 2017. [DOI: 10.1016/j.angio.2016.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kontopodis N, Galanakis N, Tsetis D, Ioannou CV. Commentary: Preoperative Aortic Morphology Identifies Patients at High Risk for Late Failure of Endovascular Aneurysm Repair. J Endovasc Ther 2017; 24:418-420. [PMID: 28440114 DOI: 10.1177/1526602817704627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Nikolaos Kontopodis
- 1 Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
| | - Nikolaos Galanakis
- 2 Interventional Radiology Unit, Department of Radiology, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
| | - Dimitrios Tsetis
- 2 Interventional Radiology Unit, Department of Radiology, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
| | - Christos V Ioannou
- 1 Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
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Mazzaccaro D, Sciarrini M, Nano G. The challenge of gate cannulation during endovascular aortic repair: A hypothesis of simplification. Med Hypotheses 2016; 94:43-6. [DOI: 10.1016/j.mehy.2016.06.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/30/2016] [Accepted: 06/13/2016] [Indexed: 10/21/2022]
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