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Fornasari A, Perini P, Gargiulo M, Silingardi R, Michelagnoli S, Bonardelli S, Bellosta R, Freyrie A. Endograft Thrombosis as indication for Open Conversion after EVAR in a multicenter experience over 25 years. Ann Vasc Surg 2024:S0890-5096(24)00294-2. [PMID: 38944191 DOI: 10.1016/j.avsg.2024.04.018] [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: 02/13/2024] [Revised: 03/26/2024] [Accepted: 04/10/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVES To describe the outcomes of aortic endograft thrombosis (AET) as an indication for open conversion (OC) after endovascular aortic aneurysm repair (EVAR) in a multicenter experience. METHODS This study retrospectively analyzed cases of OC for AET following EVAR across 12 Italian Vascular Surgery centers from 1997 to September 2022. The endpoints were as follows: 30-days mortality and major postoperative complications. Follow-up data included: survival and aortic-related complications. RESULTS Sixteen patients (mean age: 68.6±8.5 years) were included. Median elapsed time between EVAR to OC was 26.46 months (IQR 13.8-45.9). Proximal aortic cross-clamping site was supraceliac in 8 out of 16 (50%) patients, complete removal of the stentgraft was achieved in 75% of cases (12/16 patients). Reconstructions were: aorto-bi-iliac grafts in 8 cases (50%), 7 aorto-bi-femoral bypass grafts (43.8%), and 1 aorto-aortic tube graft (6.3%). All patients were symptomatic at presentation (68.7% unilateral acute limb ischemia, 25% bilateral acute limb ischemia, 1 patient had chronic severe claudication). Thirty-day mortality was 12.5% (2/16 patients). Overall morbidity rate was 43.8% (7 of 16 patients). No specific risk factors for early mortality were found. The overall estimated survival rate was 80.4% at 1 year, 62.5% at 2 years and 41.7% at 3 years. CONCLUSIONS OC for AET is typically reserved for complex cases that are not amenable to endovascular solutions. The frequent need for suprarenal clamping and complete endograft removal seem to be associated with high short-term mortality.
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Affiliation(s)
- Anna Fornasari
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paolo Perini
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy; Vascular Surgery, Cardio-Thoracic and Vascular Department, University Hospital of Parma, Parma, Italy.
| | - Mauro Gargiulo
- Vascular Surgery, University of Bologna, Department of Medical and Surgical Sciences, Bologna, Italy; Bologna Vascular Surgery Unit, IRCCS University Hospital S. Orsola, Bologna, Italy
| | - Roberto Silingardi
- Vascular Surgery, Department of Biomedical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Michelagnoli
- Vascular and Endovascular Surgery, Department of Surgery, USL Toscana Centro, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Stefano Bonardelli
- Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Raffaello Bellosta
- Vascular Surgery, Department of Surgery, "Poliambulanza" Foundation Hospital, Brescia, Italy
| | - Antonio Freyrie
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy; Vascular Surgery, Cardio-Thoracic and Vascular Department, University Hospital of Parma, Parma, Italy
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Yamanaka K, Hasegawa S, Kawabata R, Shiraki H, Chomei S, Inoue T, Tsujimoto T, Miyahara S, Takahashi H, Okada K. Anterolateral thoracotomy with partial sternotomy: a feasible approach for treating the complex pathology of the aortic arch. Eur J Cardiothorac Surg 2024; 65:ezae138. [PMID: 38597899 DOI: 10.1093/ejcts/ezae138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/20/2024] [Accepted: 04/06/2024] [Indexed: 04/11/2024] Open
Abstract
OBJECTIVES Our goal was to review our surgical experiences in patients with complex pathologies of the aortic arch who have undergone anterolateral thoracotomy with a partial sternotomy (ALPS). METHODS From October 2019 to November 2023, a total of 23 patients underwent one-stage repairs of complex pathologies of the aortic arch through the ALPS approach. The mean age was 61.9 ± 16.7 years old. The aortic pathologies were as follows: aorta-related infection in 11 (aorto-oesophageal fistula: 4, graft infection: 6, native aortic infection: 1); aortic dissection in 9 including shaggy aorta in 2, non-dissecting aneurysm in 1, and coarctation of the aorta (CoA) in 2. RESULTS Eighteen patients underwent aortic replacement from either the sinotubular junction or the ascending aorta to the descending aorta; 1 patient underwent it from the aortic root to the descending aorta (redo Bentall procedure and extensive aortic arch replacement); 3 patients underwent it from the aortic arch between the left carotid artery and left subclavian artery to the descending aorta; and 1 patient underwent a descending aortic replacement. Ten patients underwent omentopexy, latissimus dorsi muscle flap installation or both procedures. The hospital mortality rate was 13.0% (3/23). The overall survival and freedom from aortic events were 73.3%±10.2% and 74.1%±10.2%, respectively, at the 3-year follow-up. There was an absence of aorta-related deaths, and no recurrent infections were identified. CONCLUSIONS The short-term outcomes using the ALPS approach for the treatment of complex pathologies of the aortic arch were acceptable. Further studies will be required to determine the long-term results.
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Affiliation(s)
- Katsuhiro Yamanaka
- The Department of Surgery, Division of Cardiovascular Surgery, University of Kobe, Kobe, Japan
| | - Shota Hasegawa
- The Department of Surgery, Division of Cardiovascular Surgery, University of Kobe, Kobe, Japan
| | - Ryo Kawabata
- The Department of Surgery, Division of Cardiovascular Surgery, University of Kobe, Kobe, Japan
| | - Hironaga Shiraki
- The Department of Surgery, Division of Cardiovascular Surgery, University of Kobe, Kobe, Japan
| | - Shunya Chomei
- The Department of Surgery, Division of Cardiovascular Surgery, University of Kobe, Kobe, Japan
| | - Taishi Inoue
- The Department of Surgery, Division of Cardiovascular Surgery, University of Kobe, Kobe, Japan
| | - Takanori Tsujimoto
- The Department of Surgery, Division of Cardiovascular Surgery, University of Kobe, Kobe, Japan
| | - Shunsuke Miyahara
- The Department of Surgery, Division of Cardiovascular Surgery, University of Kobe, Kobe, Japan
| | - Hiroaki Takahashi
- The Department of Surgery, Division of Cardiovascular Surgery, University of Kobe, Kobe, Japan
| | - Kenji Okada
- The Department of Surgery, Division of Cardiovascular Surgery, University of Kobe, Kobe, Japan
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Hüttl A, Nagy Z, Szentiványi A, Szeberin Z, Csobay-Novák C. [Secondary ruptures of an abdominal aortic aneurysm treated with a physician-modified fenestrated endograft, endoanchors and finally with open repair]. Orv Hetil 2023; 164:1426-1431. [PMID: 37695716 DOI: 10.1556/650.2023.32856] [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: 05/23/2023] [Accepted: 06/12/2023] [Indexed: 09/13/2023]
Abstract
Secondary rupture is a late complication of endovascular aneurysm repair (EVAR). Open surgery is a technically feasible treatment option in most cases, however, late conversion carries a significant risk of morbidity and mortality, as it usually requires at least partial explantation of the in situ device, which is of major concern especially if suprarenal fixation is present. Endovascular treatment of these cases is usually challenging, especially since the custom-made devices that are often needed are not readily available but having a production time of several weeks. To overcome this limitation, physician-modified stent grafts are getting accepted to treat such urgent cases. We present the case of a patient receiving EVAR who later experienced two ruptures, treated first with a physician-modified endograft and adjunctive endoanchoring, later with open ligation of the lumbar arteries. Orv Hetil. 2023; 164(36): 1426-1431.
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Affiliation(s)
- Artúr Hüttl
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Intervenciós Radiológiai Tanszék Budapest, Határőr út 18., 1122 Magyarország
| | - Zsuzsa Nagy
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Érsebészeti és Endovaszkuláris Tanszék Budapest Magyarország
| | - András Szentiványi
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Intervenciós Radiológiai Tanszék Budapest, Határőr út 18., 1122 Magyarország
| | - Zoltán Szeberin
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Érsebészeti és Endovaszkuláris Tanszék Budapest Magyarország
- 3 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Semmelweis Aortacentrum Budapest Magyarország
| | - Csaba Csobay-Novák
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Intervenciós Radiológiai Tanszék Budapest, Határőr út 18., 1122 Magyarország
- 3 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Semmelweis Aortacentrum Budapest Magyarország
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Chiesa R, Rinaldi E, Kahlberg A, Tinaglia S, Santoro A, Colacchio G, Melissano G. Outcomes following Management of Complex Thoracoabdominal Aneurysm by an Open Approach. J Clin Med 2023; 12:jcm12093193. [PMID: 37176634 PMCID: PMC10179404 DOI: 10.3390/jcm12093193] [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: 03/16/2023] [Revised: 04/11/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND In the last decade, advances in surgical techniques, and the introduction of adjuncts for organ protection, have modified the approach for thoracoabdominal aortic aneurysm (TAAA) surgical repair. The aim of this study is to determine whether the contemporary approach influenced the outcomes. METHODS From 1989 to 2022, patients who had received elective open surgical repair (OSR) for TAAA at our institution were retrospectively analyzed. This series has been divided in two groups: Group 1 (1989-2009), and Group 2 (2010-2022). Patients included in Group 1 were those treated with a selective use of adjuncts, and Group 2 included patients treated with the systematic use of adjuncts. RESULTS A total of 1107 patients were treated (Group 1: 455; Group 2: 652). The surgical management was significantly different between the two groups. The in-hospital mortality was significantly different between the two groups (Group 1: 13.4%, Group 2: 8.1%; p 0.004), as was the rate of permanent spinal cord ischemia (Group 1: 11.9%, Group 2: 7.8%; p 0.023). Renal and respiratory failure were reduced in Group 2, but not significantly. CONCLUSIONS The use of the adjuncts enabled the achievement of improvement in mortality and SCI prevention in TAAA OSR. Although a refined surgical technique, mortality and morbidity are still noteworthy in this complex aortic field.
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Affiliation(s)
- Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132 Milan, Italy
| | - Enrico Rinaldi
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132 Milan, Italy
| | - Andrea Kahlberg
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132 Milan, Italy
| | - Sarah Tinaglia
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132 Milan, Italy
| | - Annarita Santoro
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132 Milan, Italy
| | - Giovanni Colacchio
- Department of Vascular and Endovascular Surgery, General Regional Hospital Ente Ecclesiastico "F. Miulli", 70021 Acquaviva delle Fonti, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132 Milan, Italy
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Chernyavsky MA, Chernov AV, Kazantsev AN. [Implantation of a fenestriated stent-graft in a patient with thoracic aortic aneurysm]. Khirurgiia (Mosk) 2023:111-114. [PMID: 36748878 DOI: 10.17116/hirurgia2023021111] [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: 02/08/2023]
Abstract
The authors present endovascular treatment of a patient with stenosis of the left anterior descending artery, chronic DeBakey type III aortic dissection and thoracic aortic aneurysm. The first stage was percutaneous coronary intervention with stenting of the left anterior descending artery. The second stage implied implantation of a fenestrated stent-graft. The follow-up CT angiography after 6 months revealed occlusion of the left subclavian artery that required stenting. Control CT angiography confirmed adequate stent-graft placement without endoleaks and stenosis of the artery. The choice of these reconstructions and stages of interventions are substantiated. The authors concluded effectiveness of treatment strategy, as well as the need for preventive subclavian artery stenting after implantation of a fenestrated graft.
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Affiliation(s)
- M A Chernyavsky
- Almazov National Medical Research Center, St. Petersburg, Russia
| | - A V Chernov
- Almazov National Medical Research Center, St. Petersburg, Russia
| | - A N Kazantsev
- St. Petersburg City Aleksandrovskaya Hospital, Russia, St. Petersburg
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Sen I, Kanzafarova I, Yonkus J, Mendes BC, Colglazier JJ, Shuja F, DeMartino RR, Kalra M, Rasmussen TE. Clinical presentation, operative management, and long-term outcomes of rupture after previous abdominal aortic aneurysm repair. J Vasc Surg 2023; 77:396-405.e7. [PMID: 36272507 DOI: 10.1016/j.jvs.2022.08.005] [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: 05/08/2022] [Revised: 07/30/2022] [Accepted: 08/08/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate the presentation trends, intervention, and survival of patients who had been treated for late abdominal aortic aneurysm rupture (LAR) after open repair (OR) or endovascular aortic aneurysm repair (EVAR). METHODS We reviewed the clinical data from a single-center, retrospective database for patients treated for LAR from 2000 to 2020. The end points were the 30-day mortality, major postoperative complication, and survival. The outcomes between LAR managed with EVAR (group I) vs OR were compared (group II). RESULTS Of 390 patients with infrarenal aortic rupture, 40 (10%) had experienced aortic rupture after prior aortic repair and comprised the LAR cohort (34 men; age 78 ± 8 years). LAR had occurred before EVAR in 30 and before OR in 10 patients. LAR was more common in the second half of the study with 32 patients after 2010. LAR after prior OR was secondary to ruptured para-anastomotic pseudoaneurysms. After initial EVAR, LAR had occurred despite reintervention in 17 patients (42%). The time to LAR was shorter after prior EVAR than after OR (6 ± 4 vs 12 ± 4 years, respectively; P = .003). Treatment for LAR was EVAR for 25 patients (63%; group I) and OR for 15 (37%, group II). LAR after initial OR was managed with endovascular salvage for 8 of 10 patients. Endovascular management was more frequent in the latter half of the study period. In group I, fenestrated repair had been used for seven patients (28%). Salvage for the remaining cases was feasible with EVAR, aortic cuffs, or limb extensions. The incidence of free rupture, time to treatment, 30-day mortality (8% vs 13%; P = .3), complications (32% vs 60%; P = .1), and disposition were similar between the two groups. Those in group I had had less blood loss (660 vs 3000 mL; P < .001) and less need for dialysis (0% vs 33%; P < .001) than those in group II. The median follow-up was 21 months (interquartile range, 6-45 months). The overall 1-, 3-, and 5-year survival was 76%, 52%, and 41%, respectively, and was similar between groups (28 vs 22 months; P = .48). Late mortality was not related to the aorta. CONCLUSIONS LAR after abdominal aortic aneurysm repair has been encountered more frequently in clinical practice, likely driven by the frequency of EVAR. However, most LARs, including those after previous OR, can now be salvaged with endovascular techniques with lower morbidity and mortality.
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Affiliation(s)
- Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
| | - Irina Kanzafarova
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jennifer Yonkus
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Todd E Rasmussen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
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Jacobs CR, Scali ST, Filiberto A, Anderson E, Fazzone B, Back MR, Cooper M, Upchurch GR, Huber TS. Psoas Muscle Area as a Prognostic Factor for Survival in Patients Undergoing EVAR Conversion. Ann Vasc Surg 2022; 87:1-12. [PMID: 36058454 DOI: 10.1016/j.avsg.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/05/2022] [Accepted: 08/15/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE EVAR conversion(EVAR-c) is increasingly reported and known to be technically complex and physiologically demanding. It has been proposed that pragmatic anthropomorphic measures such as psoas muscle area(PMA) may reliably quantify levels of preoperative frailty and be used to inform point of care clinical decision making and patient discussions for a variety of complex operations. To date, there is mixed data supporting use of PMA as a prognostic factor in fenestrated endovascular and open AAA repairs; however, no literature exists evaluating the impact of preoperative PMA on EVAR-c results. Therefore, the purpose of this study was to review our EVAR-c experience and evaluate the association of PMA with perioperative and long-term mortality outcomes. METHODS A retrospective single-center review of all AAA repairs was performed(2002-2019) and EVAR-c procedures were subsequently analyzed(n=153). Cross-sectional PMA at the mid-body of the L3 vertebrae was measured. The lowest PMA tertile was used as a threshold value to designate patients as having "low" PMA(n=51) and this cohort was subsequently compared to subjects with "normal" PMA(n=102). Cox proportional hazards modeling was used to estimate covariate association with all-cause mortality. RESULTS Patients with low PMA were older(77 vs. 72 years;p=.002), more likely to be female(27% vs. 5%;p<.001), and had reduced BMI(26 vs. 29kg/m2;p=.002). Time to conversion, total number of EVAR reinterventions prior to conversion and elective EVAR-c presentation incidence were similar; however, patients with low PMA had larger aneurysms(8.3 vs. 7.5cm;p=.01) and increased post-EVAR sac growth(2.3 vs. 1cm;p=.005). Unadjusted inpatient mortality was significantly greater for low PMA patients(16% vs. normal PMA, 5%, p=.02). Similarly, the total number of complications was higher among low PMA subjects(1.5±1.9 vs. normal PMA, 0.9±1.5;p=.02). Although frequency of major adverse cardiovascular events and new onset inpatient hemodialysis were similar, low PMA patients had a more than four-fold increased likelihood of having persistent requirement of hemodialysis at discharge(18% vs. 4%,p=.01). The low PMA group had decreased survival at 1 and 5 years, respectively(77±5%, 65±6% vs. normal PMA, 86±3%, 82%±5%;log-rank p=.03). Low PMA was an independent predictor of mortality with every 100mm2 increase in PMA being associated with a 15% reduction in mortality(HR 0.85,95% CI, .74-.97;p=.02). CONCLUSION Among EVAR-c patients, subjects with low preoperative PMA had higher rates of postoperative complications and worse overall survival. PMA assessments may be a useful adjunct to supplement traditional risk-stratification strategies when patients are being considered for EVAR-c.
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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.
| | - Amanda Filiberto
- Division of Vascular Surgery and Endovascular Therapy; University of Florida, Gainesville
| | - Erik Anderson
- Division of Vascular Surgery and Endovascular Therapy; University of Florida, Gainesville
| | - Brian Fazzone
- 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
| | - Michol Cooper
- Division of Vascular Surgery and Endovascular Therapy; University of Florida, Gainesville
| | - Gilbert R Upchurch
- 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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Melloni A, Kahlberg A, Rinaldi E, Bilman V, Favia N, Melissano G, Chiesa R. Open Thoracoabdominal Aortic Procedures following Endovascular Intervention. AORTA (STAMFORD, CONN.) 2022; 10:162-168. [PMID: 36521807 PMCID: PMC9754861 DOI: 10.1055/s-0042-1750117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 04/12/2022] [Indexed: 12/23/2022]
Abstract
Open conversion of thoracoabdominal aortic (TAA) disease after failed attempts of endovascular treatment is increasingly required. The main causes are endoleak, endograft failure, infection, disease progression, or persistent false lumen perfusion in dissected aortas. Mortality and morbidity rates are high, higher than after standard TAA open repair. Therefore, this surgery should be performed only in dedicated centers by experienced teams. Specific perioperative organ protection protocols, as well as surgical techniques, are crucial to guarantee acceptable results.
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Affiliation(s)
- Andrea Melloni
- Division of Vascular Surgery, Vita-Salute San Raffaele University, Ospedale San Raffaele, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Kahlberg
- Division of Vascular Surgery, Vita-Salute San Raffaele University, Ospedale San Raffaele, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Enrico Rinaldi
- Division of Vascular Surgery, Vita-Salute San Raffaele University, Ospedale San Raffaele, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Victor Bilman
- Division of Vascular Surgery, Vita-Salute San Raffaele University, Ospedale San Raffaele, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Favia
- Division of Vascular Surgery, Vita-Salute San Raffaele University, Ospedale San Raffaele, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Germano Melissano
- Division of Vascular Surgery, Vita-Salute San Raffaele University, Ospedale San Raffaele, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, Vita-Salute San Raffaele University, Ospedale San Raffaele, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
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Xodo A, D’Oria M, Mendes B, Bertoglio L, Mani K, Gargiulo M, Budtz-Lilly J, Antonello M, Veraldi GF, Pilon F, Milite D, Calvagna C, Griselli F, Taglialavoro J, Bassini S, Wanhainen A, Lindstrom D, Gallitto E, Mezzetto L, Mastrorilli D, Lepidi S, DeMartino R. Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes. J Pers Med 2022; 12:jpm12071018. [PMID: 35887518 PMCID: PMC9317732 DOI: 10.3390/jpm12071018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/06/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient's quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.
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Affiliation(s)
- Andrea Xodo
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Mario D’Oria
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
- Correspondence: ; Tel.: +39-0403994645
| | - Bernardo Mendes
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” San Raffaele University, 58-20132 Milan, Italy;
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Mauro Gargiulo
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Jacob Budtz-Lilly
- Department of Cardiovascular Surgery, Division of Vascular Surgery, Aarhus University Hospital, 161-8200 Aarhus, Denmark;
| | - Michele Antonello
- Vascular and Endovascular Surgery, University Hospital of Padova, DSCTV-University of Padova, 35128 Padova, Italy;
| | - Gian Franco Veraldi
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Fabio Pilon
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Domenico Milite
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Cristiano Calvagna
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Filippo Griselli
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Jacopo Taglialavoro
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Silvia Bassini
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - David Lindstrom
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Enrico Gallitto
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Luca Mezzetto
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Davide Mastrorilli
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Sandro Lepidi
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Randall DeMartino
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
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10
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MUSCATO P, FRANCHIN M, VELO S, CAVI R, GUZZETTI L, TOZZI M, PIFFARETTI G. Results of open conversion with full endograft explantation after failed EVAR. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.23736/s1824-4777.22.01539-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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11
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Salvati S, Bilman V, Melloni A, Baccellieri D, Kahlberg A, Melissano G, Chiesa R, Bertoglio L. Late surgical conversion of failed Multilayer Flow Modulator stenting in thoraco-abdominal aneurysms. Interact Cardiovasc Thorac Surg 2022; 34:111-119. [PMID: 34999791 PMCID: PMC8923416 DOI: 10.1093/icvts/ivab224] [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: 03/25/2021] [Revised: 05/27/2021] [Accepted: 07/13/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to report the outcomes of open or hybrid repair of failed thoraco-abdominal aortic aneurysm endovascular treatment with Multilayer Flow Modulator (MFM) stents. METHODS All patients who underwent open or hybrid repair of a failed MFM aortic treatment were retrospectively analysed. Perioperative and postoperative data, as well as midterm survival, were assessed. RESULTS Between 2013 and 2020, 39 patients received an open or hybrid conversion after endovascular treatment. Five of them [13%; 4 males; median age 68 years (interquartile range 66-76)] were previously treated with aortic MFM stents (Cardiatis, Isnes, Belgium). Among these, the median interval between index repair and conversion was 84 months (interquartile range 75-84). The median aneurysm diameter was 9.6 cm (interquartile range 8-10). Renovisceral vessels steno-occlusion was highly prevalent: 2 renal arteries were occluded; 3 coeliac trunks, 2 renal arteries and 1 superior mesenteric artery had a >70% ostial stenosis. Open standard thoraco-abdominal aneurysm conversion was performed in 3 fit patients, while a hybrid approach with visceral debranching and tube endografting was performed in 2 high-risk patients. Two patients (2 open repairs) died intraoperatively, and 1 (hybrid repair) postoperatively. The 2 successfully treated patients are alive at 4- and 34-month follow-up, respectively, with patent visceral branches. CONCLUSIONS Open or hybrid thoraco-abdominal aortic aneurysm treatment after failed endovascular aortic repair with MFM stents might be the only surgical option to address sac enlargements and ruptures or branch-related failures. However, both procedures had a poor prognosis due to both the impaired preoperative patient's status and the surgical complexity in the presented series.
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Affiliation(s)
- Simone Salvati
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” University, Milan, Italy
| | - Victor Bilman
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” University, Milan, Italy
| | - Andrea Melloni
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” University, Milan, Italy
| | - Domenico Baccellieri
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” University, Milan, Italy
| | - Andrea Kahlberg
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” University, Milan, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” University, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” University, Milan, Italy
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12
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D'Oria M, Budtz-Lilly J, Lindstrom D, Lundberg G, Jonsson M, Wanhainen A, Mani K, Unosson J. Comparison of Early and Mid-Term Outcomes After Fenestrated-Branched Endovascular Aortic Repair in Patients With or Without Prior Infrarenal Repair. J Endovasc Ther 2021; 29:544-554. [PMID: 34781751 DOI: 10.1177/15266028211058686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The purpose of this study was to compare short- and mid-term outcomes of fenestrated-branched endovascular repair (F-BEVAR) of pararenal (PRAA)/thoracoabdominal (TAAA) aortic aneurysms in patients with or without prior endovascular/open (EVAR/OAR) infrarenal aortic repair. METHODS Data from consecutive F-BEVAR (2010-2019) at two high-volume aortic centers were retrospectively reviewed. Primary endpoints were technical success, 30-day mortality, and overall survival. Secondary endpoints included 30-day major adverse events (MAE), freedom from type I/III endoleaks, reinterventions, sac expansion, and target vessel (TV) primary patency. RESULTS A total of 222 consecutive patients were included for analysis; of these 58 (26.1%) had prior infrarenal repair (EVAR=33, OAR=25) and 164 (73.9%) had native PRAA/TAAA. At baseline, patients with prior infrarenal repair were older (mean age=75.1 vs 71.6 years, p=.005) and the proportion of females was lower (8.6% vs 29.3%, p=.002). Technical success was 97.8% (n=217) in the entire cohort, without any significant differences between study groups (94.8% vs 98.8%, p=.08). At 30 days, there were no significant differences between patients with prior infrarenal repair as compared with those without in rate of MAE (44.8% vs 54.9%, p=.59). The 5-year estimate of survival for those who underwent native aortic repair was 61.6%, versus 61.3% for those who had a previous repair (p=.67). The 5-year freedom from endoleaks I/III estimates were significantly lower in patients who had prior infrarenal repair as compared with patients undergoing treatment of native aneurysms (57.1% vs 66.1%, p=.03), mainly owing to TV-related endoleaks (ie, type IC and/or IIIC endoleaks). No significant differences were found between study groups in rates of reinterventions and TV primary patency. Five-year estimates of freedom from sac increase >5mm were significantly lower in patients who received F-BEVAR after previous infrarenal repair as compared with those who underwent treatment of native aneurysms (48.6% vs 77.5%, p=.002). CONCLUSIONS F-BEVAR is equally safe and feasible for treatment of patients with prior infrarenal repair as compared with those undergoing treatment for native aneurysms. Increased rates of TV-related endoleaks were observed which could lead to lower freedom from aneurysm sac shrinkage during follow-up. Nevertheless, the 5-year rates of reinterventions and TV patency were similar, thereby indicating that overall effectiveness of treatment remained satisfactory at mid-term.
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Affiliation(s)
- Mario D'Oria
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.,Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste-ASUGI, Trieste, Italy
| | - Jacob Budtz-Lilly
- Division of Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - David Lindstrom
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Goran Lundberg
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Jonsson
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Jon Unosson
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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13
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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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14
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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: 11] [Impact Index Per Article: 3.7] [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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