Outcomes of Endovascular Abdominal Aortic Aneurysm Repair in Patients with Hostile Neck Anatomy

Safety and Efficacy of Endovascular Aortic Repair for Abdominal Aortic Aneurysms with a Hostile Neck Anatomy

OBJECTIVE

This study aimed to investigate the safety and efficacy of endovascular aortic repair (EVAR) for the treatment of an abdominal aortic aneurysm (AAA) with a hostile neck anatomy (HNA).

METHODS

From January 1, 2015 to December 31, 2019, a total of 259 patients diagnosed with an AAA who underwent EVAR were recruited into this study. Based on the morphological characteristics of the proximal neck anatomy, the patients were divided into the HNA group and the friendly neck anatomy (FNA) group. The patients were followed up for up to 4 years.

RESULTS

The average follow-up time was 1056.1±535.5 days. Type I endoleak occurred in 4 patients in the HNA group, and 2 patients in the FNA group. Neither death nor intraoperative switch to open repair occurred in either group. The time of the operation was significantly longer in the HNA group (FNA vs. HNA, 99.2±51.1 min vs. 117.5±63.8 min, P=0.011). There were no significant differences in short-term clinical success rate (P=0.228) or midterm clinical success rate (P=0.889) between the two groups. The overall mortality rate was 10.4%, and Kaplan-Meier survival analysis indicated that the two groups had similar cumulative survival rates at the end of the follow-up period (P=0.889).

CONCLUSION

EVAR was feasible and safe in patients with an AAA with a proximal HNA. The early and midterm results were promising; however, further studies are needed to verify the long-term effectiveness of EVAR.

Identifying Patients at High Risk for Post-EVAR Aneurysm Sac Growth

PURPOSE

Post-EVAR (endovascular aneurysm repair) aneurysm sac growth can be seen as therapy failure as it is a risk factor for post-EVAR aneurysm rupture. This study sought to identify preoperative patient predictors for developing post-EVAR aneurysm sac growth.

MATERIAL AND METHODS

A systematic review was conducted to select potential predictive preoperative factors for post-EVAR sac growth (including a total of 34.886 patients), which were evaluated by a retrospective single-center analysis of patients undergoing EVAR between 2009 and 2019 (N=247) with pre-EVAR computed tomography scans and at least 1 year follow-up. The primary study outcome was post-EVAR abdominal aortic aneurysm (AAA) sac enlargement (≥5 mm diameter increase). Multivariate Cox regression and Kaplan-Meier survival curves were constructed.

RESULTS

Potential correlative factors for post-EVAR sac growth included in the cohort analysis were age, sex, anticoagulants, antiplatelets, renal insufficiency, anemia, low thrombocyte count, pulmonary comorbidities, aneurysm diameter, neck diameter, neck angle, neck length, configuration of intraluminal thrombus, common iliac artery diameter, the number of patent lumbar arteries, and a patent inferior mesenteric artery. Multivariate analysis showed that infrarenal neck angulation (hazard ratio, 1.014; confidence interval (CI), 1.001-1.026; p=0.034) and the number of patent lumbar arteries (hazard ratio, 1.340; CI, 1.131-1.588; p<0.001) were associated with post-EVAR growth. Difference in estimated freedom from post-EVAR sac growth for patients with ≥4 patent lumbar arteries versus <4 patent lumbar arteries became clear after 2 years: 88.5% versus 100%, respectively (p<0.001). Of note, 31% of the patients (n=51) with ≥4 patent lumbar arteries (n=167) developed post-EVAR sac growth. In our cohort, the median maximum AAA diameter was 57 mm (interquartile range [IQR] = 54-62) and the median postoperative follow-up time was 54 months (IQR = 34-79). In all, 23% (n=57) of the patients suffered from post-EVAR growth. The median time for post-EVAR growth was 37 months (IQR = 24-63). In 46 of the 57 post-EVAR growth cases (81%), an endoleak was observed; 2.4% (n=6) of the patients suffered from post-EVAR rupture. The total mortality in the cohort was 24% (n=60); 4% (n=10) was AAA related.

CONCLUSIONS

This study showed that having 4 or more patent lumbar arteries is an important predictive factor for postoperative sac growth in patients undergoing EVAR.

CLINICAL IMPACT

This study strongly suggests that having 4 or more patent lumbar arteries should be included in preoperative counseling for EVAR, in conjunction to the instructions for use (IFU).

Engineering In Situ Weldable Vascular Devices

(1) Background: The minimally invasive implantation of medical devices is largely limited by their insertion profile, and, therefore, minimizing them constitutes a leading trend in the field. (2) Methods: This study introduces the in situ welding strategy, whereby the components of the stent grafts used to treat abdominal aortic aneurysms were decoupled, deployed sequentially, and welded together at the aneurysmal site, greatly reducing their insertion profile. Polyurethane elastomers were used to produce the graft and to coat the metallic struts of the stent to render it in vivo weldable. Results: The composition of the polyurethanes was fine-tuned, so to minimize the insertion profiles and optimize the welding properties and the clinical performance of the devices assembled. The stent and graft were deployed successively in pigs via a small 8F introducer, in situ welded, and the patency of the bi-component device was confirmed over a three-month post-implantation period. The strength of the stent/graft welded connection was fully retained, with no de-welding observed. Conclusions: The in situ welding strategy resulted in implantations that were easier to perform and markedly less injurious to tissues and organs, largely expanding the applicability of these ultra-minimally invasive procedures to especially frail segments of the population.

A Comparison of the Short-Term Outcomes After use of Aorto-Uni-Iliac Versus Bifurcated Endografts for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

BACKGROUND

To compare short-term outcomes of endovascular aneurysm repair (EVAR) with aorto-uni-iliac (AUI) versus bifurcated (BIFUR) endografts in ruptured abdominal aortic aneurysm (rAAA).

METHODS

A total of 26 rAAA patients receiving EVAR with AUI device (14 patients) or the BIFUR graft (12 patients) between January 2016 and December 2020 were enrolled and reviewed. All EVARs for rAAA were performed in an emergency basis. Graft implantation success, short-term survival rates, and major complications were analyzed.

RESULTS

Endograft implantation success was achieved in all patients. AUI group had shorter operative time than BIFUR group (121.77 ± 75.03 vs. 138.45 ± 143.34; P < 0.05). The 24-hr and 30-day survival rates were 85.7% (12/14) and 71.4% (10/14), respectively, whereas BIFUR group have 58.3% and 58.3%. None of the rAAA patients in both groups required reintervention. AUI group exhibited less incidence of compartment syndrome and endoleak compared with those of BIFUR ones.

CONCLUSIONS

The short-term results of EVAR with the AUI configuration graft in patients with rAAAs are encouraging.

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

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

Open Abdominal Aortic Aneurysm Surgery and Renal Dysfunction; Association of Demographic and Clinical Variables with Proximal Clamp Location

BACKGROUND

While cross-clamp site is a known risk factor for postoperative acute and chronic renal dysfunction following open abdominal aortic aneurysm surgery (AAA), the additive impact of patient demographic and clinical factors is lacking. In this study, we investigated the impact of body mass index (BMI), surgical duration and aneurysm diameter on the association between proximal cross-clamp location and postoperative renal dysfunction.

METHODS

In this study, we conducted a retrospective analysis of 4,197 patients undergoing open AAA surgery between 2011 and 2018 using data housed in the American College of Surgeons National Safety Quality Improvement Program (ACS-NSQIP) database. The primary outcome was renal dysfunction, which was defined as patients requiring dialysis within 30 days or patients with ≥2 mg/dL rise in creatinine from baseline. We assessed the incidence of renal dysfunction with regard to clamp location and subsequently used multivariable logistic regression to assess clinical and demographic factors associated with renal dysfunction. We used a regression model to plot the association of BMI, surgical duration, and aneurysm diameter with an adjusted probability of postoperative acute and chronic renal dysfunction for individual cross-clamp locations.

RESULTS

Of the 4,197 patients analyzed, 405 patients (9.6%) developed renal dysfunction within 30 days with 287 patients requiring dialysis. Patients with supraceliac clamp location had the highest incidence of renal dysfunction (20.4%). Our data showed a significant association of renal dysfunction with higher BMI patients [OR 1.04 (1.02, 1.07), P = 0.001], longer operative times [OR1.01 (1.01, 1.02), P < 0.001], clamp location between the superior mesenteric artery (SMA) and renal artery [OR 1.80 (1.17, 2.78), P = 0.007] and supraceliac clamp location [OR 2.47 (1.62, 3.76), P < 0.001].

CONCLUSIONS

The incidence of renal dysfunction increases with suprarenal clamps. Patients with higher BMI, longer operative times, and increasing aneurysm diameter, and a suprarenal clamp have a significantly increased risk of renal dysfunction compared to those who also had a suprarenal clamp but lower BMI, shorter operative times and smaller aneurysm diameter.

Predictors of Aneurysm Sac Shrinkage Utilizing a Global Registry

BACKGROUND

Aneurysm sac remodeling is a complex multifactorial process with unknown factors influencing sac regression after endovascular aortic aneurysm repair (EVAR). We sought to identify factors associated with this process by analyzing data obtained from patients treated with the GORE EXCLUDER endovascular aneurysm repair (EVAR) endoprosthesis from December 2010 to October 2016 enrolled in the Global Registry for Endovascular Aortic Treatment (GREAT).

METHODS

All patients enrolled in GREAT with three years CT angiography (CTA) follow-up in each of the three successive years after EVAR were included. The percentage of sac size reduction toward device diameter was calculated and used as a surrogate for sac regression with the formula used being: sac size reduction = ((AAA baseline diameter - AAA diameter at follow-up)/(AAA baseline diameter - device diameter))∗100. The cohort was divided into two groups in accordance with the percentage of aneurysm sac reduction at three years; one with the top quartile of patients and the other with the lowest three quartiles. Demographic and procedural variables were analyzed using univariate and regression modeling to determine factors predictive of sac regression.

RESULTS

There were 3265 subjects enrolled with follow-up as of May 2018 of which 526 (16.2%) had three years of CTA surveillance. Overall aneurysm sac size decreased from a mean of 58.0 mm (Std Dev: 10.4, range: 34.2, 100.0) to a mean of 49.3 mm (Std Dev: 14.1, range: 0, 140) for a percentage reduction toward device diameter of a mean 28.2% (Std Dev: 39.0, range: -103.7, 183.9). On multivariate logistic regression model; two factors proved to be statistically significant contributors to a larger percentage reduction in aneurysm sac: a conical neck (odds ratio [OR] = 1.64, P-value = 0.023) and a larger proximal device diameter (OR = 1.09, P-value = 0.023). On the other hand, two factors were negative predictors of sac shrinkage, namely: old age (OR = 0.96, P-value = 0.002) and larger baseline aneurysm sac diameter (OR = 0.98, P-value = 0.028).

CONCLUSIONS

Aneurysms with conical necks and larger proximal device neck diameters have an increased percentage change in sac size over time after EVAR. Older age and larger initial diameters of aneurysms were negatively associated with percentage change in sac size as well as sac regression. Further study is needed to determine the clinical utility of these observations and applicability across multiple endoprosthesis platforms.

In Situ Generated Medical Devices

Medical devices play a major role in all areas of modern medicine, largely contributing to the success of clinical procedures and to the health of patients worldwide. They span from simple commodity products such as gauzes and catheters, to highly advanced implants, e.g., heart valves and vascular grafts. In situ generated devices are an important family of devices that are formed at their site of clinical function that have distinct advantages. Among them, since they are formed within the body, they only require minimally invasive procedures, avoiding the pain and risks associated with open surgery. These devices also display enhanced conformability to local tissues and can reach sites that otherwise are inaccessible. This review aims at shedding light on the unique features of in situ generated devices and to underscore leading trends in the field, as they are reflected by key developments recently in the field over the last several years. Since the uniqueness of these devices stems from their in situ generation, the way they are formed is crucial. It is because of this fact that in this review, the medical devices are classified depending on whether their in situ generation entails chemical or physical phenomena.

Current evidence on aortic remodeling after endovascular repair

Anatomical changes after endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs) are thoroughly studied as they could affect the long-term postoperative outcome. The aim of the present study was to review the literature and summarize the recent data regarding the aortic remodeling and its clinical significance. A continuous aortic neck expansion is observed after EVAR and is more rapid at the first month and during the third postoperative year. This aortic neck dilation is not influenced by the type of proximal stent-graft fixation, is comparable to open surgical aneurysm repair and is most probably related with the natural progression of aneurismal disease. Aortic neck angulation reduces significantly immediately after EVAR and then continues to reduce slowly and gradually. Neck angulations ≥60° have a greater reduction compared to neck angulations <60°. An expansion of the common iliac arteries at the distal landing zone is also observed after EVAR and is more prominent in the first six postoperative months. A postoperative increase of the distance between superior mesenteric artery and iliac bifurcations (aortoiliac elongation) is described and is associated with increased type I endoleaks and reinterventions. The aneurysm sac diameter most frequently reduces after EVAR in absence of an endoleak and this aneurysm sac regression has been associated with the stent-graft type.

Global Post-Market Clinical Follow-up of the Treovance Stent-Graft for Endovascular Aneurysm Repair: One-Year Results From the RATIONALE Registry

PURPOSE:

To evaluate the safety and performance of the Treovance stent-graft.

METHODS:

The global, multicenter RATIONALE registry ( ClinicalTrials.gov; identifier NCT03449875) prospectively enrolled 202 patients (mean age 73.0±7.8 years; 187 men) with abdominal aortic aneurysms (AAA) suitable for endovascular aneurysm repair (EVAR) using the Treovance. The composite primary safety endpoint was site-reported all-cause mortality and major morbidity. The primary efficacy outcome was clinical success. Further outcomes evaluated included technical success; stent-graft migration, patency, and integrity; endoleak; and aneurysm size changes.

RESULTS:

Technical success was 96% (194/202); 8 patients had unresolved type I endoleaks at the end of the procedure. There was no 30-day mortality and 1% major morbidity (1 myocardial infarction and 1 bowel ischemia). Clinical success at 1 year was confirmed in 194 (96%) patients; 6 of 8 patients had new/persistent endoleaks and 2 had aneurysm expansion without identified endoleak. A total of 8 (4%) reinterventions were required during the mean 13.7±3.1 months of follow-up (median 12.8). At 1 year, the Kaplan-Meier estimate for freedom from reintervention was 95.6% (95% CI 91.4% to 97.8%). Other estimates were 95.5% (95% CI 91.7% to 97.6%) for freedom from endoleak type I/III and 97.4% (95% CI 94.2% to 98.9%) for freedom from aneurysm expansion. Thirteen (6.4%) patients died; no death was aneurysm related.

CONCLUSION:

The RATIONALE registry showed favorable safety and clinical performance of the Treovance stent-graft for the treatment of infrarenal AAAs in a real-world setting.

Abdominal aorta aneurysm with hostile neck: Early outcomes in outside instruction for use in patients using the treovance® stent graft

Purpose:

The efficacy and safety of endovascular aneurysm repair (EVAR), in patients outside instruction for use (IFU), is very challenging and widely debated. The aim of this study was to evaluate the placement of the Treovance^® abdominal aorta stent-graft in patients with hostile proximal necks considered outside IFU.

Materials and Methods:

Between May 2013 and August 2014, 5 patients with outside IFU underwent EVAR with the Treovance^® stent-graft. Technical and clinical successes were evaluated. All 5 patients underwent clinical and imaging follow-up.

Results:

Technical and clinical successes were achieved in all 5 patients without adjunctive endovascular procedures or surgical conversion. During the mean follow-up of 21 months, no type I/III endoleaks, stent-graft migration nor kinking/occlusion were observed. In all 5 patients, a reduction of the proximal neck angle was observed.

Conclusion:

In our small series of selected outside IFU patients, EVAR with the Treovance^® stent-graft was technically feasible and safe, with satisfactory short-term follow-up results, when performed by experienced operators. Long-term follow-up will be necessary to confirm the durability of our preliminary promising results.

Clinical Outcomes of Endovascular Aneurysm Repair with the Kilt Technique for Abdominal Aortic Aneurysms with Hostile Aneurysm Neck Anatomy: A Korean Multicenter Retrospective Study

PURPOSE

We aimed to evaluate the clinical efficacy and short-term clinical outcomes of Kilt technique-based endovascular aneurysm repair (EVAR) with Seal^® stent-grafts for abdominal aortic aneurysms (AAAs) with hostile neck anatomy (angle > 60°).

MATERIALS AND METHODS

We retrospectively evaluated the pre-EVAR and follow-up computed tomography angiography findings of 24 patients (mean age 71 ± 11 years; age range 32-87 years; mean follow-up 50 ± 12 months) with hostile neck AAAs treated between 2010 and 2015. Serial change in aneurysmal neck angle was calculated using a standardized protocol. Relationships between clinical variables and outcomes were evaluated using univariate and multivariate Cox analyses and mixed-model regression. In addition, the Kaplan-Meier method was used to assess the cumulative rates of survival, endoleak, and reintervention.

RESULTS

The primary technical success rate (success within 24 h after EVAR) was 100% (24/24). The survival rate was 96 ± 8% at 1 month, 6 months, 1 year, and 3 years, and 87 ± 18% at 5 years. Endoleaks occurred in three patients. Four reinterventions were performed in three patients; no surgical revisions were required. Causes of post-EVAR mortality included intracerebral hemorrhage at 14 days and rhabdomyolysis at 32 months. The most remarkable change after Kilt-based EVAR was an acute decrease in the neck angle, which was observed between the pre-EVAR and first follow-up visits (at 1 month) (P = 0.001).

CONCLUSION

Kilt-based EVAR with Seal^® stent-grafts for AAAs with a severely angulated neck (angle > 60°) provided high technical success, low mortality, and low complication rates during short-term follow-up.

Could Preoperative Neck Anatomy Influence Follow-up of EVAR?

BACKGROUND

The aim of the study was to assess the clinical utility of strict CT scan surveillance after endovascular abdominal aneurysm repair (EVAR) and evaluate whether the anatomy of abdominal aortic aneurysm (AAA) neck (favorable/hostile) influences regular imaging control.

METHODS

A retrospective study of AAA patients who underwent EVAR with aortobi-iliac endoprostheses during 2006-2013 was conducted. Exclusion criteria included other types of devices. Variables analyzed were technical and clinical success, morbimortality, complications (such as endoleaks, sac enlargement), reinterventions, reintervention-free survival, and survival rate. Preoperative CT scans were performed and repeated at 1, 6 (in selective cases), 12, and 24 months postoperatively. Patients were divided into two groups according to preoperative anatomic characteristics: group I (favorable neck) and group II (hostile neck: angle > 60°, length < 15 mm, diameter > 28 mm, and calcification or circumference thrombus ≥50%).

RESULTS

A total of 127 patients with AAA (96.8% male) were included in the study. The mean age of the patients was 75.9 years (range: 51-90 years). The mean AAA diameter was 62.1 mm. Hostile neck was found in 52 patients (40.9%). The technical and clinical success rate was 100% and 30-day mortality was 0.8%. The reintervention-free survival rate was 97.6%, 96.1%, and 93.7% and the survival rate was 97.6%, 96.9%, and 91.3%, during follow-up at 6, 12, and 24 months, respectively. Accumulated complications in proximal sealing occurred in 0%, 0%, and 1.6% in group I and 1.9%, 6.1%, and 7.7% in group II at 1, 12, and 24 months, respectively. Type II endoleaks occurred in 24.3%, 14.3%, and 11.4% in group I and 9.8%, 6.3%, and 6.8% in group II at 1, 12, and 24 months, respectively. No increased diameter was detected at 6 and 12 months. No differences were observed in reinterventions and mortality rate depending on anatomy.

CONCLUSIONS

CT scans performed at 6 and 12 months postoperatively did not detect complications or need for reintervention in patients with favorable necks, even in the presence of endoleaks type II, and could therefore be omitted. Hostile necks may compromise proximal sealing and require regular imaging follow-ups.

Thrombotic Occlusion of Stent Graft Limbs due to Severe Angulation of Aortic Neck in Endovascular Repair of Abdominal Aortic Aneurysm

Endovascular aneurysm repair (EVAR) is a safe alternative to open surgical repair for an abdominal aortic aneurysm. However, unfavorable aortic anatomy of the aneurysm has restricted the widespread use of EVAR. Anatomic limitation is most often related to characteristics of the proximal neck anatomy. In this report, we described a patient with a severely angulated proximal neck who underwent EVAR, but required repeat intervention because of thrombotic occlusion of stent graft limbs.

Challenging Anatomy Predicts Mortality and Complications After Endovascular Treatment of Ruptured Abdominal Aortic Aneurysm

Purpose: To analyze the effects of aortic anatomy and endovascular aneurysm repair (EVAR) inside and outside the instructions for use (IFU) on outcomes in patients treated for ruptured abdominal aortic aneurysms (rAAA). Methods: All 112 patients (mean age 73 years; 102 men) treated with standard EVAR for rAAA between 2000 and 2012 in 3 European centers were included in the retrospective analysis. Patients were grouped based on aortic anatomy and whether EVAR was performed inside or outside the IFU. Data on complications, secondary interventions, and mortality were extracted from the patient records. Cox regression analysis was performed to assess predictors of mortality and complications; results are presented as the hazard ratio (HR) with 95% confidence interval (CI). Survival was analyzed using the Kaplan-Meier method. Results: Of the 112 patients examined, 61 (54%) were treated inside the IFU, 43 (38%) outside the IFU, and 8 patients lacked adequate preoperative computed tomography scans for determination. Median follow-up of those surviving 30 days was 2.5 years. Mortality at 30 days was 15% (95% CI 6% to 24%) inside the IFU vs 30% (95% CI 16% to 45%) outside (p=0.087). Three-year mortality estimates were 33.8% (95% CI 20.0% to 47.5%) inside the IFU vs 56% (95% CI 39.7% to 72.2%) outside (p=0.016). At 5 years, mortality was 48% (95% CI 30% to 66%) inside the IFU vs 74% (95% CI 54% to 93%) outside (p=0.015). Graft-related complications occurred in 6% (95% CI 0% to 13%) inside the IFU and 30% (95% CI 14% to 42%) outside (p=0.015). The rate of graft-related secondary interventions was 14% (95% CI 4% to 22%) inside the IFU vs 35% (95% CI 14% to 42%) outside (p=0.072). In the multivariate analysis, neck length <15 mm (HR 8.1, 95% CI 3.0 to 21.9, p<0.001) and angulation >60° (HR 3.1, 95% CI 1.0 to 9.3, p=0.045) were independent predictors of late graft-related complications. Aneurysm neck diameter >29 mm (HR 2.5, 95% CI 1.1 to 5.9, p=0.035) was an independent predictor of overall mortality. Conclusion: Long-term mortality and complications after rEVAR are associated with aneurysm anatomy. The role of adjunct endovascular techniques and the outcome of open repair in cases with challenging anatomy warrant further study.

Novel Risk Score Model for Prediction of Survival Following Elective Endovascular Abdominal Aortic Aneurysm Repair

OBJECTIVE

The purpose of this study was to identify significant predictors of long-term mortality after elective endovascular abdominal aortic aneurysm repair (EVAR).

METHODS

We included all cases with elective EVAR based on a national data set from the Society for Vascular Surgery Patient Safety Organization. Clinical and anatomic variables were analyzed with a Kaplan-Meier and Cox-regression model to determine predictors of mortality and develop a score equation to categorize patients into low, medium, and high long-term mortality risk.

RESULTS

A total of 5678 patients with EVAR were included with an average age of 73.6 ± 8.2 years. The majority were male (81.6%) with a history of smoking (86.1%). There were 3 deaths within 30 days (0.1%). Several factors were associated with poor survival: unstable angina (hazard ratio [HR], 2.8; P = .008), dialysis (HR, 3.7; P < .001), estimated glomerular filtration rate (eGFR) <30 (HR, 1.7; P = .044), eGFR 30 to 59 (HR, 1.4; P = .002), age >80 (HR, 3.2; P < .001), age 75 to 79 (HR, 2.2; P < .001), chronic obstructive pulmonary disease on oxygen (HR, 3.3; P < .001), aortic diameter >5.8 cm (HR, 1.2; P = .043), and high risk for surgery (HR, 1.4; P = .043). Preoperative aspirin use and body mass index 25 to 35 were both found to be protective (HR, 0.78; P = .017 and HR, 0.8; P = .024, respectively). With our scoring model, 5- and 10-year survival rates for patients with low, medium, and high risk were 89.2%, 80.7%, and 64.1% and 77.2%, 60.1%, and 40.1%, respectively (P < .001).

CONCLUSION

Ten-year survival following EVAR in patients with a high-risk score utilizing the model provided was 40.1%. Patients with multiple comorbidities at risk for decreased long-term survival can be identified with our model, which is more applicable for high-volume contemporary institutions.

Endovascular repair of abdominal aortic aneurysms: vascular anatomy, device selection, procedure, and procedure-specific complications

Abdominal aortic aneurysm (AAA) is abnormal dilatation of the aorta, carrying a substantial risk of rupture and thereby marked risk of death. Open repair of AAA involves lengthy surgery time, anesthesia, and substantial recovery time. Endovascular aneurysm repair (EVAR) provides a safer option for patients with advanced age and pulmonary, cardiac, and renal dysfunction. Successful endovascular repair of AAA depends on correct selection of patients (on the basis of their vascular anatomy), choice of the correct endoprosthesis, and familiarity with the technique and procedure-specific complications. The type of aneurysm is defined by its location with respect to the renal arteries, whether it is a true or false aneurysm, and whether the common iliac arteries are involved. Vascular anatomy can be divided more technically into aortic neck, aortic aneurysm, pelvic perfusion, and iliac morphology, with grades of difficulty with respect to EVAR, aortic neck morphology being the most common factor to affect EVAR appropriateness. When choosing among the devices available on the market, one must consider the patient's vascular anatomy and choose between devices that provide suprarenal fixation versus those that provide infrarenal fixation. A successful technique can be divided into preprocedural imaging, ancillary procedures before AAA stent-graft placement, the procedure itself, postprocedural medical therapy, and postprocedural imaging surveillance. Imaging surveillance is important in assessing complications such as limb thrombosis, endoleaks, graft migration, enlargement of the aneurysm sac, and rupture. Last, one must consider the issue of radiation safety with regard to EVAR.

Aortic Neck Anatomic Features and Predictors of Outcomes in Endovascular Repair of Abdominal Aortic Aneurysms Following vs Not Following Instructions for Use

BACKGROUND

A significant number of patients undergo endovascular repair of abdominal aortic aneurysms (EVAR) outside the instructions for use (IFU). This study will examine various aortic neck features and their predictors of clinical outcomes.

STUDY DESIGN

We performed a retrospective analysis of prospectively collected data on EVAR patients. Neck features outside IFU were analyzed. Kaplan-Meier and multivariate analyses were used to predict their effect as single features, or in combination, on outcomes.

RESULTS

Fifty-two percent of 526 patients had 1 or more features outside the IFU. The overall technical success rate was 99%, and perioperative complication rates were 7% and 12% for IFU vs outside IFU use, respectively (p = 0.04). Type I early endoleak and early intervention rates were 7% and 10% for IFU vs 18% and 24% for outside IFU (p = 0.0002 and p < 0.0001). At a mean follow-up of 30 months, freedom from late type I endoleak and late reintervention at 1, 2, and 3 years for IFU were 99.5%, 99.5%, and 98.4%, and 99.4%, 98%, and 96.8%; vs 98.9%, 98.1%, and 98.1%, and 97.5%, 96.2%, and 95.2% for outside IFU (p = 0.049 and 0.799), respectively. Survival rates at 1, 2, and 3 years for IFU were 97%, 93.5%, and 89.8%; vs 93.7%, 88.8%, and 86.3% for outside IFU (p = 0.035). Multivariate analysis showed that a neck angle > 60 degrees had odds ratios for death, sac expansion, and early intervention of 6, 2.6, and 3.3, respectively; neck length < 10 mm had odds ratios of 2.8 for deaths, 3.4 for early intervention, 4.6 for late reintervention, and 4.3 for late type I endoleak.

CONCLUSIONS

Patients with neck features outside IFU can be treated with EVAR; however, they have higher rates of early and late type I endoleak, early intervention, and late death.

Outcomes Following Limb Crossing in Endovascular Aneurysm Repairs

Background:

Crossing the limbs of the stent during endovascular aneurysm repair (EVAR) is often used to aid cannulation of the contralateral limb. This study assessed outcomes following the use of this technique.

Methods:

Retrospective review of crossed (n = 43) and uncrossed (n = 269) EVARs was performed at a tertiary vascular center over 5 years. Primary end points were graft limb occlusion (GLO), endoleak, and sac expansion rates. Indications for limb crossing were also assessed.

Results:

Two-year GLO ( P = .34) and type 1 endoleak ( P = .413) rates were similar between groups. Patients undergoing crossed EVAR experienced more type 2 endoleaks ( P = .002) at 24 months but no increase in sac expansion rates was observed ( P = .275). Thirty-day ( P = .57) and late ( P = .268) mortalities were similar between groups. The main indication for limb crossing was distal aortic angulation (48.8%).

Conclusions:

Crossed EVAR does not increase the risk of GLOs or clinically significant endoleaks. Further studies are needed to determine the effect on type 2 endoleak rates.

Changes in suprarenal and infrarenal aortic angles after endovascular aneurysm repair

Purpose

We investigated whether suprarenal and infrarenal aortic angles change after the endovascular aneurysm repair (EVAR) procedure and during follow-up, and investigated the correlation between infrarenal aortic angle after EVAR and type Ia endoleaks.

Methods

Data collected on 70 EVAR procedures for a fusiform infrarenal aortic aneurysm performed between May 2006 and December 2012 were supplemented with a retrospective review of charts and radiographs.

Results

The greater the preoperative infrarenal aortic angle, the greater the suprarenal aortic angle (r = 0.72, P < 0.001). The infrarenal aortic angle decreased after the EVAR procedure and continued to decrease slowly thereafter (all P < 0.001). Suprarenal aortic angle decreased immediately after the EVAR procedure and continued to decrease during the first month (P < 0.001). No differences in angulation were observed based on stent graft type. Type Ia endoleaks occurred with significantly greater incidence in patients with a larger post EVAR infrarenal angle (P = 0.037).

Conclusion

The infrarenal aortic angle decreased significantly immediately after the EVAR procedure and continued to decrease slowly thereafter. Suprarenal aortic angle decreased immediately after the EVAR procedure and continued to decrease during the first month. We found a correlation between infrarenal and suprarenal aortic angle. Type Ia endoleaks occurred with greater incidence in patients with a larger infrarenal angle immediately after EVAR.

Immediate and two-year outcomes after EVAR in "on-label" and "off-label" neck anatomies using different commercially available devices. analysis of the experience of two Italian vascular centers

BACKGROUND

Endovascular aneurysm repair (EVAR) has fast become the therapeutic strategy of choice for abdominal aortic aneurysms (AAAs). Nowadays, the most important limit to the effectiveness of this technique is represented by complex anatomical situations, especially regarding the morphology of the proximal sealing zone. The aim of this study was to evaluate the 2-year outcome of unselected, real-world patients with "off-label" (off-L) proximal necks treated in 2 high-volume Italian vascular centers.

METHODS

A double-center study was conducted on a prospectively compiled computerized database between January 2010 and December 2011. One hundred and ninety-six consecutive elective surgery patients were analyzed and divided into 2 groups ("on-label" [on-L] and "off-L" necks) on the basis of their aortic neck anatomy. The neck was classified as an "off-L neck" in the presence of: (1) a noncylindrical neck, (2) an angulated neck, (3) a short neck, and (4) an enlarged neck. The end points were 30-day and 2-year technical and clinical success, evaluated in terms of freedom from reintervention and death.

RESULTS

One hundred and thirty-three elective patients were treated by standard EVAR in the presence of an "off-L" proximal neck anatomy. Technical success was achieved in all cases in both groups. Six (9.5%) unplanned adjunctive procedures were necessary in the on-L group and 16 (12%) in the off-L group (P = ns). Perioperative endoleaks, reinterventions, stent-graft migration rates, and AAA-related deaths were null. A multivariate analysis was performed to evaluate the subgroups of patients with 2 or > 2 anatomic factors that indicate a challenging neck. In patients with 2 such factors, a significant difference was observed in terms of intraoperative adjunctive procedures, intraoperative endoleaks, and all-cause mortality: 26.7% vs. 9.9% (P = 0.048), 6.7% vs. 0.5% (P = 0.023), and 13.3% vs. 1.1% (P = 0.0012), respectively. The same differences became increasingly evident when analyzing patients with > 2 criteria: 50% vs. 10% (P = 0.0022), 16.7% vs. 0.5% (P < 0.001), and 16.7% vs. 1.0% (P = 0.01). No AAA-related deaths or AAA ruptures were reported in either group at the end of the 2-year follow-up. High-flow endoleaks, stent-graft migration, and, consequently, reintervention were more frequent in the off-L group, but none of these parameters reached statistical significance.

CONCLUSIONS

Our experience seems to show that the off-L use of EVAR could be considered effective for the treatment of patients unfit for open surgery. In patients with more than one anatomical proximal neck feature contraindicating open surgery, the rate of immediate complications and reinterventions was higher, but this did not affect the clinical benefit and success at 2-year follow-up.

Endovascular treatment of infrarenal abdominal aortic aneurysm with short and angulated neck in high-risk patient

Endovascular treatment of abdominal aortic aneurysms (AAA) is an established alternative to open repair. However lifelong surveillance is still required to monitor endograft function and signal the need for secondary interventions (Hobo and Buth 2006). Aortic morphology, especially related to the proximal neck, often complicates the procedure or increases the risk for late device-related complications (Hobo et al. 2007 and Chisci et al. 2009). The definition of a short and angulated neck is based on length (<15 mm), and angulation (>60°) (Hobo et al. 2007 and Chisci et al. 2009). A challenging neck also offers difficulties during open repairs (OR), necessitating extensive dissection with juxta- or suprarenal aortic cross-clamping. Patients with extensive aneurysmal disease typically have more comorbidities and may not tolerate extensive surgical trauma (Sarac et al. 2002). It is, therefore, unclear whether aneurysms with a challenging proximal neck should be offered EVAR or OR (Cox et al. 2006, Choke et al. 2006, Robbins et al. 2005, Sternbergh III et al. 2002, Dillavou et al. 2003, and Greenberg et al. 2003). In our case the insertion of a thoracic endograft followed by the placement of a bifurcated aortic endograft for the treatment of a very short and severely angulated neck proved to be feasible offering acceptable duration of aneurysm exclusion. This adds up to our armamentarium in the treatment of high-risk patients, and it should be considered in emergency cases when the fenestrated and branched endografts are not available.

Women with abdominal aortic aneurysms have more extensive aortic neck pathology

BACKGROUND

The proportion of women with abdominal aortic aneurysm (AAA) treated with endovascular aortic repair (EVAR) is lower than for open repair (OR). Unfavorable morphologic features for EVAR in women with AAA may explain this disproportion. The objective of this study was to identify morphologic features in AAA patients undergoing elective repair with special emphasis on gender differences.

METHODS

Patients undergoing elective repair from January 1, 2006 to December 31, 2008 at our university's vascular unit were included in this study. Computed tomography (CT) angiograms were analyzed. Morphologic features considered unfavorable for EVAR rather than open repair (OR) included: infrarenal aortic neck <15 mm; angulation >60°; circumferential neck thrombus; neck width >32 mm; iliac arteries <7.5 mm; or presence of bi-iliac aneurysms. Complex aortic neck was defined as a neck length of <15 mm and one or more of the other aortic neck exclusion criteria.

RESULTS

One hundred seventy-two patients, including 140 men and 32 women, were treated during the study period, which included 99 with OR (21 women, 78 men) and 73 with EVAR (11 women, 62 men). Morphologic unsuitability for EVAR was 44% (75 of 172) and was not statistically different between women and men [47% (15 of 32) vs. 43% (60 of 140), P = 0.70]. Aortic neck pathology was the dominating feature for unsuitability for EVAR (69 of 75, 92%), and 85 of 172 patients had an unsuitable aortic neck. This rate was not different between women and men [19 of 32 (59%) vs. 66 of 140 (47%), P = 0.24]. Iliac unsuitability rates were 11% (19 of 172) and were not different between women and men [4 of 32 (12%) vs. 15 of 140 (11%), P = 0.76]. In patients unsuitable for EVAR, the proximal aortic necks showed more extensive aortic neck pathology in women than in men [8 of 15 (53%) vs. 13 of 60 (22%), P = 0.02]. More men had only short neck pathology [22 of 60 (37%) vs. 1 of 15 (7%), P = 0.03].

CONCLUSIONS

Aortic neck pathology is the dominating cause of EVAR exclusion in both genders. A higher proportion of women have more pathologic neck anatomy. Future development of EVAR devices should focus on the complexity of the aortic neck, which will benefit all AAA patients, but especially women.

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

OBJECTIVE

To evaluate outcomes after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) with neck thrombus.

METHODS

We retrospectively reviewed patients who underwent EVAR for AAA at our institution from 2007 to 2011. Patients with ruptured AAA, chronic renal failure, or hostile neck characteristics other than thrombus were excluded. Patients were divided into 2 groups: group T (with neck thrombus) and group N (without neck thrombus). We compared complications and mid-term outcomes.

RESULTS

There were no differences in success rates between the groups, but there were higher rates of thromboembolic complications such as distal embolization (20% vs 0%, P = .02) and renal dysfunction (36.8% vs 11.1%, P = .03) in group T than in group N. Suprarenal thrombus and suprarenal fixation in the presence of suprarenal thrombus were associated with postoperative renal dysfunction (P = .01).

CONCLUSION

The EVAR for AAA with neck thrombus is associated with thromboembolic complications.

A systematic review of protocols for the three-dimensional morphologic assessment of abdominal aortic aneurysms using computed tomographic angiography

The morphology of infrarenal abdominal aortic aneurysms (AAAs) directly influences the perioperative outcome and long-term durability of endovascular aneurysm repair. A variety of methods have been proposed for the characterization of AAA morphology using reconstructed three-dimensional (3D) computed tomography (CT) images. At present, there is lack of consensus as to which of these methods is most applicable to clinical practice or research. The purpose of this review was to evaluate existing protocols that used 3D CT images in the assessment of various aspects of AAA morphology. An electronic search was performed, from January 1996 to the end of October 2010, using the Embase and Medline databases. The literature review conformed to PRISMA statement standards. The literature search identified 604 articles, of which 31 studies met inclusion criteria. Only 15 of 31 studies objectively assessed reproducibility. Existing published protocols were insufficient to define a single evidence-based methodology for preoperative assessment of AAA morphology. Further development and expert consensus are required to establish a standardized and validated protocol to determine precisely how morphology relates to outcomes after endovascular aneurysm repair.

A meta-analysis of outcomes of endovascular abdominal aortic aneurysm repair in patients with hostile and friendly neck anatomy

BACKGROUND

An increasing number of abdominal aortic aneurysms with unfavorable proximal neck anatomy are treated with standard endograft devices. Skepticism exists with regard to the safety and efficacy of this practice.

METHODS

A systematic review of the literature was undertaken to identify all studies comparing the outcomes of endovascular aneurysm repair (EVAR) in patients with hostile and friendly infrarenal neck anatomy. Hostile neck conditions were defined as conditions that were not consistent with the instructions for use of the endograft devices employed in the selected studies. Outcome data were pooled, and combined overall effect sizes were calculated using fixed or random effects models.

RESULTS

Seven observational studies reporting on 1559 patients (hostile anatomy group, 714 patients; friendly anatomy group, 845 patients) were included. Patients with hostile anatomy required an increased number of adjunctive procedures to achieve proximal seal compared with patients with friendly anatomy (odds ratio [OR], 3.050; 95% confidence interval [CI], 1.884-4.938). Although patients with unfavorable neck anatomy had an increased risk of developing 30-day morbidity (OR, 2.278; 95% CI, 1.025-5.063), no significant differences in the incidence of type I endoleak and reintervention rates within 30 days of treatment between the two groups were identified (OR, 2.467 and 1.082; 95% CI, 0.562-10.823 and 0.096-12.186). Patients with hostile anatomy had a fourfold increased risk of developing type I endoleak (OR, 4.563; 95% CI, 1.430-14.558) and a ninefold increased risk of aneurysm-related mortality within 1 year of treatment (OR, 9.378; 95% CI, 1.595-55.137).

CONCLUSIONS

Insufficient high-level evidence for or against performing standard EVAR in patients with hostile neck anatomy exists. Our analysis suggests EVAR should be cautiously used in patients with anatomic neck constraints.

Outcomes of endovascular aneurysm repair in patients with hostile neck anatomy

OBJECTIVES

This study aims to evaluate outcomes following EVAR in patients with hostile neck anatomy (HNA).

METHODS

Data prospectively collected from 552 elective EVARs were analysed retrospectively. Data regarding neck morphology was obtained from aneurysm stent plans produced prior to EVAR. HNA was defined as any of; neck diameter >28 mm, neck angulation >60°, neck length <15 mm, neck thrombus, or neck flare.

RESULTS

552 patients underwent EVAR. Mean age 73.9 years, mean follow-up 4.1 years. 199 patients had HNA, 353 had favourable neck anatomy (FNA). There was a significant increase in late type I endoleaks (FNA 4.5%, HNA 9.5%; P = 0.02) and total reinterventions (FNA 11.0%, HNA 22.8%; P < 0.01), and a significant decrease in late type II endoleaks in patients with HNA (FNA 16.7%, HNA 10.6%; P < 0.05). There was no significant difference in technical success (FNA 0.6%, HNA 2.0%; p = 0.12), 30-day re-intervention (FNA 2.8%, HNA 5.0%; P = 0.12), 30-day mortality (FNA 1.1%, HNA 0.5%; P = 0.45), 30-day type I endoleaks (FNA 0.8%, HNA 2.5%; P = 0.12), 5-year mortality (FNA 15.1%, HNA 14.6%; P = 0.86), aneurysm-related mortality (FNA 1.7% versus HNA 2.0%; P = 0.79), stent-graft migration (FNA 2.5%, HNA 3.0%; P = 0.75), sac expansion (FNA 13.0%, HNA 9.5%; P = 0.22), or graft rupture (FNA 1.1%, HNA 3.5%; P = 0.05). Binary logistic regression of individual features of HNA revealed secondary intervention (P = 0.009), technical failure (P = 0.02), and late type I endoleaks (P = 0.002), were significantly increased with increased neck diameter.

CONCLUSIONS

HNA AAAs can be successfully treated with EVAR. However, surveillance is necessary to detect and treat late type I endoleaks in HNA patients.

Remodeling of proximal neck angulation after endovascular aneurysm repair

OBJECTIVE

This study investigated the remodeling of proximal neck (PN) angulations of abdominal aortic aneurysms (AAAs) after endovascular aneurysm repair (EVAR).

METHODS

A 64-row multidetector computed tomography scan of AAAs treated with EVAR was reviewed, and the PN angulation was measured on a volume-rendered three-dimensional image. The computed tomography scan was examined preoperatively, after EVAR at 1 week, 1 month, 6 months, 1 year, 1.5 years, 2 years, and then yearly. The study enrolled 78 patients, comprising 54 Zenith devices (Cook Medical, Bloomington, Ind) and 24 Excluder devices (W. L. Gore and Associates, Flagstaff, Ariz).

RESULTS

PN angulation was 50° ± 20° preoperatively, and after EVAR was 36° ± 14° at 1 week, 32° ± 14° at 1 year, and 28° ± 13° at 3 years. PN angulations ≤ 60° (n = 70, 77%) were 41° ± 13° preoperatively, 31° ± 12° 1 week after EVAR, 28° ± 12° at 1 year, and 26° ± 13° after 3 years. An angulation >60° (n = 18, 23%) was 78° ± 14° preoperatively, 51° ± 11° 1 week after EVAR, 44° ± 11° at 1 year, and 40° ± 12° after 3 years. The greater the preoperative PN angulation, the greater its reduction immediately after EVAR (r = .72, P < .001). The diameter shrinkage of AAAs with a PN angulation >60° was 3 ± 6 mm after 1 year; a significantly smaller shrinkage than with a PN angulation ≤ 60° (7 ± 7 mm, P < .05). AAAs with a PN angulation >60° had a larger angulation reduction and a smaller diameter shrinkage after the EVAR procedure. The PN angulation of the 54 AAAs treated by Zenith was 49° ± 22° preoperatively, 34° ± 14° 1 week after EVAR, and 25° ± 13° after 3 years. The corresponding angulation of the 24 AAAs treated by Excluder devices was 52° ± 17°, 41° ± 14°, and 38° ± 9°, respectively. The PN angulation reduction of Zenith and Excluder was similar 1 week after the EVAR procedure. Unlike Excluder, however, the PN angulation in Zenith continued to reduce for a long period at a slow pace. There were no significant correlations between PN angulation reduction and diameter change and between PN length and diameter change (P = .86 and .18, respectively).

CONCLUSIONS

Although the instructions for use of most commercially available stent grafts provide for a PN angulation of ≤ 60°, PN angulation was not a major issue in a midterm follow-up of AAAs with adequate PN length for patients in this series who received a Zenith or Excluder graft.

AAA with a challenging neck: early outcomes using the Endurant stent-graft system

OBJECTIVES

The efficacy and safety of endovascular aneurysm repair is disputable in aneurysms with a short, angulated, wide, conical, or thrombus-lined neck making a reliable seal difficult to achieve. The influence of a challenging neck on early results using the Endurant stent-graft system in high risk patients was investigated.

MATERIALS AND METHODS

A retrospective study conducted on a prospectively compiled database of 72 elective patients with challenging neck treated with the Endurant system (Endurant Stent Graft, Medtronic AVE, Santa Rosa, CA, USA). These patients were compared to a control group (n = 65) without significant neck problems. Endpoints were early technical and clinical success, deployment accuracy and differences in operative details at one month follow-up. Data are reported as mean and standard deviation or as absolute frequency and percentage (%). Normality distribution and homogeneity of variances were tested by Shapiro-Wilks and Levene tests, respectively. Inter-group comparisons for each variable were made by t-test or χ2-test or Fisher exact test. A p < 0.05 was considered statistically significant.

RESULTS

Mean age was 76.12 years; 76.6% were males. Risk factors and pre-operative variables did not differ significantly between the two groups. Mean neck length was 10.56 mm in patients with challenging anatomies and 22.85 mm in controls. Patients with a challenging neck differed significantly (p < 0.001) from controls in terms of mean infrarenal (37.67° vs. 20.12°) and suprarenal angle (19.63° vs. 15.57°); 82% of patients with a challenging neck were ASA III/IV (vs. 86%). Technical success was 100%, with four unplanned proximal extension in challenging group. No type I endoleaks or aneurysm-related deaths occurred in either group; major complications were 1.54% vs. 1.39% (p = 0.942). Operative details were similar in both groups.

CONCLUSION

Treatment with the Endurant stent-graft is technically feasible and safe, yielding satisfactory results even in challenging anatomies. Medium- and long-term data are needed to verify durability, but early results are promising.

Technical and clinical outcome of Talent versus Endurant endografts for endovascular aortic aneurysm repair

Objective

The technical evolution of endografts for the interventional management of infrarenal abdominal aortic aneurysms (AAA) has allowed a continuous expansion of indications. This study compares the established Talent endograft with its successor, the Endurant endograft, taking individual aortoiliac anatomy into account.

Methods

From June 2007 to December 2010, 35 patients with AAA were treated with a Talent endograft (33 men) and 36 patients with an Endurant endograft (34 men). Aortoiliac anatomy was evaluated in detail using preinterventional computed tomography angiography. The 30-day outcome of both groups were compared regarding technical and clinical success as well as complications including endoleaks.

Results

The Endurant group included more patients with unfavorable anatomy (kinking of pelvic arteries, p = 0.017; shorter proximal neck, p = 0.084). Primary technical success was 91.4% in the Talent group and 100% in the Endurant group (p = 0.115). Type 1 endoleaks occurred in 5.7% of patients in the Talent group and in 2.8% of those in the Endurant group (p = 0.614). Type 3 endoleaks only occurred in the Talent group (2.9% of patients; p = 0.493). Type 2 endoleaks were significantly less common in the Endurant group than in the Talent group (8.3% versus 28.6%; p = 0.035). Rates of major and minor complications were not significantly different between both groups. Primary clinical success was significantly better in the Endurant group (97.2%) than in the Talent group (80.0%) (p = 0.028).

Conclusion

Endurant endografts appear to have better technical and clinical outcome in patients with difficult aortoiliac anatomy, significantly reducing the occurrence of type 2 endoleaks.