Simultaneous Transcatheter Aortic Valve Implantation and Endovascular Aneurysm Repair for Severe Aortic Stenosis and Symptomatic Abdominal Aortic Aneurysm: Mini Review

Background: The treatment of patients with severe aortic stenosis (SAS) who concomitantly present with abdominal aortic aneurysm (AAA) is not defined. Aortic valve replacement surgery, performed alone, increases the risk of AAA rupture. Transcatheter aortic valve replacement (TAVR) and endovascular abdominal aortic aneurysm repair (EVAR) in the same intervention, especially in high-risk patients, is a safe alternative. Purpose: We report a case of simultaneous endovascular treatment of SAS and AAA and a mini literature review of nineteen cases with similar characteristics. Research design: Case report and literature review. Data Collection: An electronic search of PubMed and Scopus was performed from inception to December 2023. Results: Nineteen case reports of simultaneous transcatheter aortic valve repair and endovascular aneurysm repair for SAS and symptomatic AAA were identified published in the literature. Conclusions: We regard the simultaneous endovascular approach to both pathologies as a promising treatment alternative for selected patients with severe aortic stenosis and abdominal aortic aneurysm. We highlight the need to conduct randomized clinical trials in this patient population.

Applying Artificial Intelligence to Predict Complications After Endovascular Aneurysm Repair

Objective: Complications after Endovascular Aneurysm Repair (EVAR) can be fatal. Patient follow-up for surveillance imaging is becoming more challenging as fewer patients are seen, particularly after the first year. The aim of this study was to develop an artificial intelligence model to predict the complication probability of individual patients to better identify those needing more intensive post-operative surveillance. Methods: Pre-operative CTA 3D reconstruction images of AAA from 273 patients who underwent EVAR from 2011-2020 were collected. Of these, 48 patients had post-operative complications including endoleak, AAA rupture, graft limb occlusion, renal artery occlusion, and neck dilation. A deep convolutional neural network model (VascAI©) was developed which utilized pre-operative 3D CT images to predict risk of complications after EVAR. The model was built with TensorFlow software and run on the Google Colab Platform. An initial training subset of 40 randomly selected patients with complications and 189 without were used to train the AI model while the remaining 8 positive and 36 negative cases tested its performance and prediction accuracy. Data down-sampling was used to alleviate data imbalance and data augmentation methodology to further boost model performance. Results: Successful training was completed on the 229 cases in the training set and then applied to predict the complication probability of each individual in the held-out performance testing cases. The model provided a complication sensitivity of 100% and identified all the patients who later developed complications after EVAR. Of 36 patients without complications, 16 (44%) were falsely predicted to develop complications. The results therefore demonstrated excellent sensitivity for identifying patients who would benefit from more stringent surveillance and decrease the frequency of surveillance in 56% of patients unlike to develop complications. Conclusion: AI models can be developed to predict the risk of post-operative complications with high accuracy. Compared to existing methods, the model developed in this study did not require any expert-annotated data but only the AAA CTA images as inputs. This model can play an assistive role in identifying patients at high risk for post-EVAR complications and the need for greater compliance in surveillance.

The Impact of Perioperative Morbidities, Lack of Discharge Aspirin, and Lack of Discharge Statin on Long Term Survival Following EVAR

OBJECTIVE

Adverse perioperative events and discharge medications both have the potential to impact survival following endovascular abdominal aortic aneurysm repair (EVAR). We hypothesize that variables such as blood loss, reoperation in the same hospital admission, and lack of discharge statin/aspirin have significant effect on long term survival following EVAR. Similarly, other perioperative morbidities, are hypothesized to affect long term mortality. Quantifying the mortality effect of perioperative events and treatment emphasizes to physicians the critical nature of preoperative optimization, case planning, operative execution and postoperative patient management.

METHODS

All EVAR in the Vascular Quality Initiative between 2003 and 2021 were queried. Exclusions were: ruptured/symptomatic aneurysm; concomitant renal artery or supra-renal intervention at the time of EVAR; conversion to open aneurysm repair at the time of initial operation; and undocumented mortality status at the 5 year mark postoperatively. 18,710 patients met inclusion criteria. Multivariable Cox regression time dependent analysis was performed to investigate the strength of mortality association of the exposure variables. Standard demographic variables and pre-existing major co-morbidities were included in the regression analysis to account for disproportionate, deleterious co-variables amongst those experiencing the various morbidities. Kaplan-Meier survival analysis was performed to provide survival curves for the key variables.

RESULTS

Mean follow up was 5.99 years and 5-year survival for included patients was 69.2%. Cox regression revealed increased long term mortality to be associated with the following perioperative events: reoperation during the index hospital admission (HR 1.21, P = .034), perioperative leg ischemia (HR 1.34, P = .014), perioperative acute renal insufficiency (HR 1.24, P = .013), perioperative myocardial infarction (HR 1.87, P < .001), perioperative intestinal ischemia (HR 2.13, P < .001), perioperative respiratory failure (HR 2.15, P < .001), lack of discharge aspirin (HR 1.26, P < .001), and lack of discharge statin (HR 1.26, P < .001). The following pre-existing co-morbidities correlated with increased long term mortality (P < .001 for all) : body mass index under 20 kg/m2, hypertension, diabetes, coronary artery disease, reported history congestive heart failure, chronic obstructive pulmonary disease, peripheral artery disease, advancing age, baseline renal insufficiency and left ventricular ejection fraction less than 50%. Females were more likely to have EBL >300 mL, reoperation, perioperative MI, limb ischemia and acute renal insufficiency than males (P < .01 for all). Female sex trended but was not associated with increased long term mortality risk (HR 1.06, 95% CI .995-1.14, P = .072).

CONCLUSIONS

Survival after EVAR is improved with optimal operative planning to facilitate evading the need for reoperation and ensuring patients without contra-indication are discharged with aspirin and statin medications. Females and patients with pre-existing co-morbidity are at particularly higher risk for perioperative limb ischemia, renal insufficiency, intestinal ischemia and myocardial ischemia necessitating appropriate preparation and preventative measures.

Factors Influencing on the Aneurysm Sac Shrinkage after Endovascular Abdominal Aortic Aneurysm Repair by the Analysis of the Patients with the Aneurysm Sac Shrinkage and Expansion

Objectives: The aneurysmal sac shrinkage has been reported as the strong predictor of favorable long-term outcome after endovascular aneurysm repair (EVAR). We evaluated the effects of perioperative and intraoperative factors on the aneurysm sac shrinkage. Methods: EVAR was performed for 296 patients during August 2009-December 2021. Nine patients with type Ia, Ib, or III; 69 patients with the sac diameter change less than 5 mm; and five patients with sac re-expansion after shrunk more than 5 mm were excluded. Thus, patients with sac shrinkage 5 mm or more (79 patients, shrinkage group) and with sac expansion 5 mm or more (18 patients) were included in this study. Antifibrinolytic therapy with tranexamic acid (TXA) 1500 mg/day for 6 months after EVAR was introduced in March 2013 and patent aortic side branches were coil embolized during EVAR since July 2015. Patients' background and patent aortic side branches at the end of EVAR were evaluated. Results: Univariate analysis for comparison between patients with sac shrinkage and sac expansion revealed that males (82.3% vs. 55.6%, p = 0.021), without antiplatelet therapy (40.5% vs. 66.7%, p = 0.044) and TXA (79.8% vs. 38.9%, p <0.001), were significantly associated with sac shrinkage. By multivariate analysis, the odds ratio of sac shrinkage was 11.7 for males, 0.1 for the patients on antiplatelet therapy, and 6.5 for the patient who received TXA. The patients with patent inferior mesenteric artery (IMA) were less in the shrinkage group (20.3% vs. 77.8%, p <0.001) and with two or less patent lumbar arteries (LAs) were more in the shrinkage group (82.3% vs. 33.3%, p < 0.001). The odd ratio of sac shrinkage was 7.8 for occluded IMA and 3.9 for two or less patent LAs. Conclusion: The possibility of sac shrinkage would be high for the patient with occluded IMA and two or less patent LA at the end of EVAR, and that patient received TXA after EVAR. (This is a translation of Jpn J Vasc Surg 2022; 31: 291-297.).

Management of Abdominal Aortic Aneurysm With Concomitant Acute Cholecystitis in the Era of Endovascular Surgery

The incidence of symptomatic acute cholecystitis with large (greater than 5.5 cm) abdominal aortic aneurysm is an uncommon occurrence. Guidelines on concomitant repair in this setting remain elusive, particularly in the era of endovascular repair. We present a case of acute cholecystitis in a 79-year-old female presenting to a local rural emergency room with abdominal pain and known abdominal aortic aneurysm (AAA). Abdominal computed tomography (CT) revealed a 5.5 cm infrarenal abdominal aortic aneurysm, significantly greater in size compared to previous imaging, as well as a distended gallbladder with mild wall thickening and cholelithiasis concerning for acute cholecystitis. The two conditions were found to be unrelated to each other, but concerns were raised on appropriate timing of care. Following diagnosis, the patient underwent concomitant treatment of acute cholecystitis and large abdominal aortic aneurysm with laparoscopic and endovascular techniques, respectively. In this report, we take the opportunity to discuss the treatment of patients with AAA and concomitant symptomatic acute cholecystitis.

Spinal Cord Ischemia Following Endovascular Abdominal Aortic Aneurysm Repair: An Unpredictable Catastrophe

Spinal cord ischemia (SCI) following endovascular abdominal aortic aneurysm (AAA) repair (EVAR) is a rare yet catastrophic complication. The underlying pathophysiological mechanism remains incompletely understood. We present the case of a 75-year-old man with a difficult left common iliac artery (CIA) anatomy that necessitated the coiling of his left internal iliac artery (IIA) to ensure proper sealing of his aortic stent graft. The patient complained of bilateral lower extremity weakness immediately following the procedure. The patient was diagnosed with SCI, which was later confirmed by magnetic resonance imaging (MRI). He was treated with cerebrospinal fluid drainage. The patient's neurological status mildly improved on follow-up one year later.

The acute impact of baseline renal function and contrast medium volume/estimated glomerular filtration rate ratio on reduced renal function following endovascular abdominal aortic aneurysm repair

OBJECTIVE

The aim of this study was to determine the acute impact of baseline serum creatinine, estimated glomerular filtration rate (eGFR), and contrast medium volume (CMV) on the incidence of reduced renal function (RRF) after endovascular abdominal aortic aneurysm repair (EVAR). We aimed to determine if the CMV/eGFR ratio was a predictor of RRF.

METHODS

This study is a retrospective review of EVAR patients in the Society for Vascular Surgery/Vascular Quality Initiative (SVS/VQI) from January 2015 to August 2020. Reduced renal function was defined as > 0.3 mg/dl (26.5 μmol/L), 50% increase from baseline, and temporary or permanent dialysis. Receiver operator characteristic (ROC) curve analyses were conducted for serum creatinine, eGFR, contrast volume, fluid volume, and CMV/eGFR ratio. Two data sets (training and test) were developed followed by multivariate analyses.

RESULTS

SVS/VQI data for EVAR contained 38,701 records, of which 30,539 were divided into training (n = 18,283; 60%) and test (n = 12,256; 40%) data sets. RRF rate for the training set was 3.6% (n = 667) and 3.4% (n = 420) for the test data. RRF patients included more females (29.4 vs 19.0%, p < 0.001), were older in age (75.6 + 8.4 vs 73.3 + 8.7 years), had more congestive heart failure (22.3 vs 12.2%, p < 0.001), and more COPD (42.0 vs 34.2%, p < 0.001). An ROC analysis revealed that eGRF, creatinine, contrast, intravenous fluid, and contrast medium volume (CMV)/eGFR ratio were all significantly (p < 0.05) correlated with RRF. The eGFR and CMV/eGFR ratio had the largest area under the curve, (0.26) and (0.65), respectively, while fluid had the lowest (0.54). Negative predictive values were 93.7 (CMV/eGFR), 93.9 (creatinine), 94.2 (eGFR), 92.8 (contrast), and 92.6 (intravenous fluid). Multivariate analysis of the training data set resulted in the CMV/eGFR ratio as an independent predictor of RRF (odds ratio, OR: 1.9 with 95% CI: 1.6, 2.2, p < 0.015). For the test data, the CMV/eGFR ratio was an independent predictor of RRF (OR: 1.8, CI: 1.4 to 2.2, p < 0.001) as well as several other variables.

CONCLUSION

RRF after EVAR is a dreaded and potentially devastating complication. Baseline serum creatinine, eGFR, contrast medium volume, and the ratio (CMV/eGFR) were all significantly associated with RRF. The optimal cut-off value for the CMV/eGFR ratio, ≤ 2, provides an easy-to-use equation to provide a suggested contrast target based on initial renal function with caution applied for high-risk patients.

Predictors of Decline in Renal Function 5 Years after EVAR

INTRODUCTION

While there exists copious short-term data regarding renal function following infra-renal endovascular abdominal aortic aneurysm repair (EVAR), long-term analysis is sparse. This is a single institution retrospective review of predictors of renal function decline 5 years after elective EVAR.

METHODS

All EVAR between 2007 and 2015 were queried. Patients in whom renal function was documented 5 years postoperatively were included in analysis. Exclusion criteria were ruptured aneurysm, mortality before 56 months, lack of follow-up, ESRD status, and concomitant renal intervention. The primary outcome investigated was a 20% or greater drop in glomerular filtration rate (GFR) 5 years postoperatively. The following variables at the time of surgery were investigated as potential predictors: age, gender, hypertension, hyperlipidemia, diabetes, CAD or prior MI, COPD, prior stroke, baseline eGFR under 60 mL/min/1.73 m², supra-renal fixation, infra-renal fixation, neck diameter, neck length, and number of contrast CT.

RESULTS

354 EVAR were identified of which 143 met inclusion criteria (211 excluded). Univariate analysis revealed female gender (OR 2.7), hypertension (OR 9.4), baseline renal insufficiency (OR 3.8), larger neck diameter, and supra-renal fixation (OR 2.32) all predictive (P < .05) of GFR drop at 5 years. Multivariate binary logistic regression analysis found female gender (multivariate OR 3.9, P = .023) and baseline renal insufficiency (multivariate OR 3.0, P = .029) as significant predictors of greater than 20% GFR drop at 5 years. Only 2 patients of the 143 progressed to dialysis requirement at 5 years.

CONCLUSIONS

Females and patients with baseline renal insufficiency are more vulnerable to significant decline in renal function 5 years following EVAR. Consistent with analogous literature, supra-renal fixation appears moderately deleterious toward renal function with no clinical significance in those with baseline normal renal function. The potential benefit of avoidance of supra-renal fixation in female patients with baseline renal insufficiency is worth further investigation in a more robust multi-center study.

[Treatment of Concomitant Intra-abdominal Malignancy and Abdominal Aortic Aneurysm]

Objective To explore the outcomes in patients who receive the endovascular abdominal aortic aneurysm repair(EVAR)and have concomitant intra-abdominal malignancy.Methods Between January 2014 and December 2019,all the patients who underwent surgery for malignancy and/or EVAR were retrospectively reviewed.Results Twenty-eight abdominal aortic aneurysm(AAA)patients with concomitant intra-abdominal malignancy were included.The patients were treated by two-stage operation and the priority was given for EVAR in 21 patients.There was no perioperative death or major complications.In the follow-up,one patient developed graft thrombosis and one had type Ⅱ endoleak.There was no AAA-associated death.Conclusions It is preferred that EVAR should come first followed by operation for malignancy.Details of treatment strategy still need further investigation.

Endovascular Aortic Repair under Extracorporeal Cardiac Support in a Patient with an Abdominal Aortic Aneurysm Impending Rupture and Aortic Stenosis: A Case Report

Aortic stenosis is a serious valvular disease that increases the risk of cardiac arrest and/or cardiogenic shock during noncardiac surgery. A 93-year-old woman with an abdominal aortic aneurysm impending rupture and aortic stenosis underwent endovascular abdominal aortic aneurysm repair. During surgery, the patient presented with ventricular tachycardia. Due to on-going cardiogenic shock, we did a direct cannulation into the right axillary artery for the immediate establishment of venoarterial extracorporeal membrane oxygenation. The endovascular treatment of the abdominal aortic aneurysm was completed according to the standard procedure. The patient recovered without any complications, including heart failure or neurological dysfunction.

Post-Endovascular Abdominal Aortic Aneurysm Repair Abdominal Pain: A Learning Experience

Abdominal aortic aneurysm (AAA) is one of the important pathologies involving the abdominal aorta, as it can have adverse consequences if it goes unnoticed or untreated. AAA is defined as an abnormal dilation of the abdominal aorta 3 cm or greater. Endovascular abdominal aortic aneurysm repair (EVAR) has recently emerged as a treatment modality for AAA. It does have a few inherent complications that include endoleak, endograft migration, bleeding, ischemia, and compartment syndrome. This case report discusses a patient who came in with abdominal pain and a pulsatile mass, which raised concerns regarding endoleak. The patient had a 9.9-cm AAA, which was repaired in the past, as was made evident by computed tomography findings of the stent graft in the aneurysmal segment. This case stands out because it highlights the importance of comparing the size of the AAA at the time of the EVAR to the current scenario where the patient presents with abdominal pain of unknown etiology. Also, this case report highlights the importance of computed tomography and other imaging forms in following-up with patients who have EVAR for AAAs.

Fatal Complications of New-Onset Complicated Type B Aortic Dissection After Endovascular Abdominal Aortic Aneurysm Repair: Report of 2 Cases and Literature Review

New-onset antegrade Stanford type B aortic dissection (TBAD) after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is rare. The extension of aortic dissection leads to various symptoms and affects the stent graft. Moreover, various symptoms may arise owing to a stent graft being present. We describe 2 cases of complicated acute TBAD occurring after EVAR, which were ultimately fatal. The case in which rupture occurred could not be treated and the patient died. In another case with bilateral lower extremity malperfusion caused by collapse and occlusion of the endograft, extra-anatomical bypass was performed. Although the collapsed endograft gradually re-expanded, the patient ultimately died because of multiorgan failure. We have reviewed the literature and analyzed the treatment of complicated TBAD after EVAR.

A Case of Intestinal Necrosis after Bilateral Internal Iliac Artery-Preserving Endovascular Repair for Abdominal Aortic Aneurysm

A 79-year-old man underwent endovascular repair for abdominal aortic aneurysm (AAA), and both internal iliac arteries (IIAs) were preserved. Postoperatively, loss of appetite developed. On the fifth day, computerized tomography (CT) showed inferior mesenteric artery thrombus formation, necrosis of the descending colon and rectum, and generalized peritonitis. The endovascular devices had not migrated. A colonic resection was performed. Histological analysis confirmed intestinal necrosis associated with mesenteric thrombus. The colon can become necrotic even if both IIAs are patent. Ischemic changes in the colon should be detected if it occurs and subsequent laparotomy should be done if it is necessary.

One-stage Procedure for Concomitant Abdominal Aortic Aneurysm and Gastric Cancer

BACKGROUND/AIM

A concise surgical strategy for concomitant abdominal aortic aneurysm (AAA) and operable gastric cancer remains unknown. We assessed a one-stage procedure that included endovascular abdominal aortic aneurysm repair (EVAR) and gastric resection.

PATIENTS AND METHODS

Forteen patients who underwent surgery for an infrarenal AAA and gastric cancer between 1990 and 2012 were retrospectively reviewed. Demographic characteristics, aneurysm size, comorbid conditions, length of postoperative hospital stay, complications within 30 days of surgery, and survival in patients in EVAR (n=4) were compared against patients who had an open AAA repair (n=10).

RESULTS

Demographic characteristics, aneurysm size, and comorbid conditions were similar in the EVAR and open-AAA-repair group. The mean length of hospitalization was significantly shorter in the EVAR group (15.2 days vs. 34.9 days; p=0.005), and the rate of postoperative complications was significantly lower (p<0.05). The overall survival rates in the EVAR and open-AAA-repair groups were, respectively, 100% and 80% at 1 year and 75% and 60% at 3 years; the differences between groups were not significant (p=0.788).

CONCLUSION

In patients with concomitant AAA and gastric cancer who are eligible for EVAR, use of a one-stage procedure including EVAR and gastric resection is feasible.

Percutaneous endovascular repair of abdominal aortic aneurysm with coexisting horseshoe kidney: technical aspects and review of the literature

Surgical repair of abdominal aortic aneurysms (AAAs) with coexisting horseshoe kidney (HSK) is technically challenging because of complex anatomy. Endovascular repair has emerged as a common approach to AAA repair and represents a valid alternative in selected patients with AAA and concomitant congenital renal anomalies. We report a case of successful percutaneous endovascular repair in a patient with coexistent AAA and HSK. Careful preoperative planning is essential in successful endovascular management of abdominal aneurysms in these patients.