Current clinical practice in postoperative endovascular aneurysm repair imaging surveillance

PURPOSE

To investigate the current clinical practice in postoperative endovascular aneurysm repair (EVAR) imaging surveillance.

MATERIALS AND METHODS

Corresponding authors of EVAR publications during the years 2006-2011 and subscribers to an endovascular journal were invited to complete a 27-question online survey related to institutional demographics, standard post-EVAR imaging surveillance, and imaging protocols in special circumstances (eg, renal insufficiency).

RESULTS

The survey was completed by 515 of 9,631 physicians performing EVAR from 52 countries. Of respondents, 65.3% were affiliated with experienced centers where EVAR has been performed for > 10 years or with > 50 EVAR procedures performed per year. Computed tomography (CT) angiography was the modality used most often for standard surveillance with a maximum time interval between studies of 12 months in 78.8% of centers out to 5 years. Experienced centers were more likely to delay follow-up imaging to 1 year after an unremarkable initial post-EVAR imaging study (P < .001), to extend surveillance intervals > 12 months (P = .043), and to use ultrasound (P < .01) for surveillance. After the detection of a type II endoleak, CT angiography was favored for follow-up by 59.4% of the respondents. Experienced centers were more likely to favor ultrasound (P = .006) and to schedule this follow-up examination later (after 6-12 months, P < .001). Of respondents, 62.8% used a glomerular filtration rate threshold of < 30 mL/min for not performing contrast-enhanced CT scan. In patients with renal insufficiency, most respondents performed ultrasound with or without a concomitant noncontrast CT scan.

CONCLUSIONS

CT is the most frequently used method of long-term surveillance after EVAR. Use of ultrasound for long-term surveillance, extension of follow-up time intervals, or both were most often reported in experienced centers.

Endovascular treatment of descending thoracic aortic disease: single-center, 15-year experience

PURPOSE

To report the experience with thoracic endovascular aortic repair (TEVAR) in a single center over a 15-year period.

MATERIALS AND METHODS

All patients undergoing TEVAR during the period 1994-2009 were retrospectively evaluated.

RESULTS

The study comprised 133 patients (96 men, age 69.5 years ± 14.7) who underwent 21 emergency and 112 elective TEVAR procedures. Aortic pathologies included 91 aneurysms, 14 pseudoaneurysms, 14 penetrating ulcers with or without pseudoaneurysms or intramural hematomas, 8 type B dissections (3 acute and 5 chronic), and 6 traumatic transections. Technical success was 97.7% with a 30-day mortality of 7.5%. There were 101 patients followed to 1 year, 35 patients followed to 5 years, and 6 patients followed to 10-15 years. The overall estimated survivals at 1 year, 5 years, and 10 years were 81%, 48%, and 36%. The 30-day mortality rates in emergency and elective TEVAR procedures were 23.9% and 4.5% (P = .005). However, among patients who survived > 30 days, there was no significant difference in mortality between groups undergoing emergency and elective TEVAR procedures (P = .9, hazard ratio [HR] 0.94, confidence interval [CI] 0.4-2.2). There was no significant gender survival difference. The 30-day mortality rate in octogenarians (n = 31) was higher than in younger patients (P = .03). Incidences of stroke and paraplegia within 30 days of TEVAR were 6.8% and 2.2%. Endoleaks were found in 39 (29%) patients, and secondary interventions were performed in 6 (4.5%) patients.

CONCLUSIONS

The data support the safety and efficacy of TEVAR for aortic pathologies with a low mortality rate. Younger patients have fewer complications after TEVAR. After the acute perioperative period, TEVAR procedures performed emergently are as durable as the procedures performed electively.

Treating the diseased superficial femoral artery

Vascular disease involving the superficial femoral artery (SFA) is common. Once the decision to treat the SFA is made, the benefits and limitations of angioplasty and stents must be applied to each specific patient. Additionally, the potential role of covered stents as well as drug eluting stents must be considered.

Anemia is associated with abdominal aortic aneurysm (AAA) size and decreased long-term survival after endovascular AAA repair

OBJECTIVE

Anemia is a common comorbid condition in various inflammatory states and an established predictor of mortality in patients with chronic heart failure, ischemic heart disease, and end-stage renal disease. The present study of patients with abdominal aortic aneurysm (AAA) undergoing endovascular repair (EVAR) assessed the relationships between baseline hemoglobin concentration and AAA size, as well as anemia and long-term survival.

METHODS

Between March 1994 and November 2006, 711 patients (65 women, mean age 75.8 +/- 7.8 years) underwent elective EVAR. Anemia was defined as a hemoglobin level <13 g/dL in men and <12 g/dL in women. Post-EVAR mean follow-up was 48.3 +/- 32.0 months. Association of hemoglobin level with AAA size was assessed with multiple linear regression. Mortality was determined with use of the internet-based Social Security Death Index and the electronic hospital record. Kaplan-Meier survival curves of anemic and nonanemic patient groups were compared by the log-rank method. Multivariable logistic regression models were used to determine the influence of anemia on vital status after EVAR.

RESULTS

A total of 218/711 (30.7%) of AAA patients undergoing EVAR had anemia at baseline. After adjustment for various risk factors, hemoglobin level was inversely related to maximum AAA diameter (beta: - .144, 95%-CI: -1.482 - .322, P = .002). Post-EVAR survival was 65.5% at 5 years and 44.4% at 10 years. In long-term follow-up, survival was significantly lower in patients with anemia as compared to patients without anemia (P < .0001 by log-rank). Baseline hemoglobin levels were independently related to long-term mortality in multivariable Cox regression analysis adjusted for various risk factors (adjusted HR: 0.866, 95% CI: .783 to .958, P = .005). Within this model, statin use (adjusted HR: .517, 95% CI: .308 to .868, P = .013) was independently related to long-term survival, whereas baseline AAA diameter (adjusted HR: 1.022, 95% CI: 1.009 to 1.036, P = .001) was an independently associated with increased mortality.

CONCLUSIONS

Baseline hemoglobin concentration is independently associated with AAA size and reduced long-term survival following EVAR. Thus, the presence or absence of anemia offers a potential refinement of existing risk stratification instruments.

Long-term Outcome from Uterine Fibroid Embolization with Tris-acryl Gelatin Microspheres: Results of a Multicenter Study

PURPOSE

To determine the long-term outcome of uterine fibroid therapy (UFE) using tris-acryl gelatin microspheres (TAGM).

MATERIALS

This was a multicenter prospective study of patients undergoing UFE with TAGM, and during this phase of the study, the clinical outcomes 3 years after treatment were assessed. Measures of outcome included the Ruta Menorrhagia Questionnaire, patient self-assessments of symptoms and impact on activities, patient satisfaction and health-related quality of life as measured by the SF-12. Long-term re-intervention rates were also assessed. The data were analyzed at each interval compared to baseline using appropriate statistical tests.

RESULTS

Of the 102 patients enrolled, 96 patients had complete baseline data and of these, 69 (72%) had known outcomes at 3 years after treatment. Sixty-one patients (64%) completed long-term follow-up without major intervention. An additional 8 patients (8.3%) underwent fibroid surgery (7 hysterectomies and 1 myomectomy). Among those without intervention, at 3 years after treatment, the mean Ruta Questionnaire Score was 19.3, compared to 47.9 at baseline and 24.5 at 3 months (P <.01). At baseline, 57% of patients had extremely heavy bleeding, while only 2% had that complaint at 36 months. At 36 months, much or moderate improvement in pelvic pain occurred in 83% of patients, pelvic discomfort in 83%, and urinary problems in 69% and 84% were moderately or very satisfied with their outcome.

CONCLUSIONS

Over the long-term, UFE using TAGM is effective and safe, with high levels of durable symptom control, improved health-related quality of life and patient satisfaction.