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Nakayama H, Toma M, Kobayashi T, Hara R, Sato Y. Pre-constrain technique using the Gore Excluder Conformable endograft for abdominal aortic aneurysm with severely angulated proximal neck. J Vasc Surg Cases Innov Tech 2024; 10:101614. [PMID: 39391025 PMCID: PMC11466632 DOI: 10.1016/j.jvscit.2024.101614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 08/09/2024] [Indexed: 10/12/2024] Open
Abstract
Endovascular aneurysm repair for abdominal aortic aneurysms with a severely angulated proximal neck remains challenging because of the higher rates of type 1a endoleaks and secondary interventions. In this study, we reviewed six consecutive patients with a severely angulated proximal neck (>60°) treated with endovascular aneurysm repair at a single center. They were treated with a Gore Excluder Conformable endograft using a pre-constrain technique to prevent type 1a endoleaks. It is the unique deployment technique of the proximal trunk by pre-constrain of the proximal edge. This technique helps obtain optimal deployment of the proximal main body.
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Affiliation(s)
- Hiroyuki Nakayama
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Taishi Kobayashi
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Ryosuke Hara
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
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Marchiori E, Ibrahim A, Schäfers JF, Oberhuber A. Embolization for Type Ia Endoleak after EVAR for Abdominal Aortic Aneurysms: A Systematic Review of the Literature. Biomedicines 2022; 10:1442. [PMID: 35740463 PMCID: PMC9220150 DOI: 10.3390/biomedicines10061442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022] Open
Abstract
(1) Successful endovascular repair for abdominal aortic aneurysms is based on the complete exclusion of the aneurysm sac from the systemic circulation. Type Ia endoleak (ELIA) is defined as the persistent perfusion of the aneurysm sac due to incomplete proximal sealing between aorta and endograft, with a consequent risk of rupture and death. Endoleak embolization has been sporadically reported as a viable treatment for ELIA. (2) A systematic literature search in PubMed of all publications in English about ELIA embolization was performed until February 2022. Research methods and reporting were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Data regarding patient numbers, technical success (endoleak absence at control angiography), reinterventions, clinical and imaging follow-up, and outcomes were collected and examined by two independent authors. (3) Twenty-one papers (12 original articles, 9 case reports) reported on 126 patients (age range 58-96 years) undergoing ELIA embolization 0-139 months after the index procedure. Indication for embolization was most often founded on unfavorable anatomy and patient comorbidities. Embolic agents used include liquid embolic agents, coils, plugs and combinations thereof. Technical success in this highly selected cohort ranged from 67-100%; the postprocedural complication rate within 30 days was 0-24%. ELIA recurrence was reported as 0-42.8%, with a secondary ELIA-embolization-intervention success rate of 50-100%. At a follow-up at 0-68 months, freedom from sac enlargement amounted to 76-100%, freedom from ELIA to 66.7-100%. (4) Specific literature about ELIA embolization is scant. ELIA embolization is a valuable bailout strategy for no-option patients; the immediate technical success rate is high and midterm and long-term outcomes are acceptable.
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Affiliation(s)
- Elena Marchiori
- Department of Vascular and Endovascular Surgery, University Hospital Münster, 48149 Münster, Germany; (A.I.); (J.F.S.); (A.O.)
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3
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Rhee R, Oderich G, Han S, Long C, Muck P, Moore E, Matsumura J. One year results of the GORE® EXCLUDER® Conformable AAA Endoprosthesis (EXCC) system in the United States regulatory trial. J Vasc Surg 2022; 76:951-959.e2. [DOI: 10.1016/j.jvs.2022.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/05/2022] [Indexed: 11/26/2022]
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Zarkowsky DS, Sorber R, Ramirez JL, Goodney PP, Iannuzzi JC, Wohlauer M, Hicks CW. Aortic Neck IFU Violations During EVAR for Ruptured Infrarenal Aortic Aneurysms are Associated with Increased In-Hospital Mortality. Ann Vasc Surg 2021; 75:12-21. [PMID: 33951521 PMCID: PMC9843606 DOI: 10.1016/j.avsg.2021.04.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Vascular surgeons treating patients with ruptured abdominal aortic aneurysm must make rapid treatment decisions and sometimes lack immediate access to endovascular devices meeting the anatomic specifications of the patient at hand. We hypothesized that endovascular treatment of ruptured abdominal aortic aneurysm (rEVAR) outside manufacturer instructions-for-use (IFU) guidelines would have similar in-hospital mortality compared to patients treated on-IFU or with an infrarenal clamp during open repair (ruptured open aortic aneurysm repair [rOAR]). METHODS Vascular Quality Initiative datasets for endovascular and open aortic repair were queried for patients presenting with ruptured infrarenal AAA between 2013-2018. Graft-specific IFU criteria were correlated with case-specific proximal neck dimension data to classify rEVAR cases as on- or off-IFU. Univariate comparisons between the on- and off-IFU groups were performed for demographic, operative and in-hospital outcome variables. To investigate mortality differences between rEVAR and rOAR approaches, coarsened exact matching was used to match patients receiving off-IFU rEVAR with those receiving complex rEVAR (requiring at least one visceral stent or scallop) or rOAR with infrarenal, suprarenal or supraceliac clamps. A multivariable logistic regression was used to identify factors independently associated with in-hospital mortality. RESULTS 621 patients were treated with rEVAR, with 65% classified as on-IFU and 35% off-IFU. The off-IFU group was more frequently female (25% vs. 18%, P = 0.05) and had larger aneurysms (76 vs. 72 mm, P= 0.01) but otherwise was not statistically different from the on-IFU cohort. In-hospital mortality was significantly higher in patients treated off-IFU vs. on-IFU (22% vs. 14%, P= 0.02). Off-IFU rEVAR was associated with longer operative times (135 min vs. 120 min, P= 0.004) and increased intraoperative blood product utilization (2 units vs. 1 unit, P= 0.002). When off-IFU patients were matched to complex rEVAR and rOAR patients, no baseline differences were found between the groups. Overall in-hospital complications associated with off-IFU were reduced compared to more complex strategies (43% vs. 60-81%, P< 0.001) and in-hospital mortality was significantly lower for off-IFU rEVAR patients compared to the supraceliac clamp group (18% vs. 38%, P= 0.006). However, there was no significantly increased mortality associated with complex rEVAR, infrarenal rOAR or suprarenal rOAR compared to off-IFU rEVAR (all P> 0.05). This finding persisted in a multivariate logistic regression. CONCLUSIONS Off-IFU rEVAR yields inferior in-hospital survival compared to on-IFU rEVAR but remains associated with reduced in-hospital complications when compared with more complex repair strategies. When compared with matched patients undergoing rOAR with an infrarenal or suprarenal clamp, survival was no different from off-IFU rEVAR. Taken together with the growing available evidence suggesting reduced long-term durability of off-IFU EVAR, these data suggest that a patient's comorbidity burden should be key in making the decision to pursue off-IFU rEVAR over a more complex repair when proximal neck violations are anticipated preoperatively.
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Affiliation(s)
- Devin S. Zarkowsky
- Divison of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Rebecca Sorber
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Joel L. Ramirez
- Division of Vascular Surgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Philip P. Goodney
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - James C. Iannuzzi
- Division of Vascular Surgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Max Wohlauer
- Divison of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
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Sirignano P, Mansour W, Capoccia L, Cuozzo S, Camparini S, de Donato G, Mangialardi N, Ronchey S, Talarico F, Setacci C, Speziale F. Endovascular aortic repair in patients with challenging anatomies: the EXTREME study. EUROINTERVENTION 2021; 16:e1544-e1550. [PMID: 31793884 PMCID: PMC9725024 DOI: 10.4244/eij-d-19-00547] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to report the 30-day technical and clinical success with endovascular repair using the ultra-low-profile Ovation stent graft in patients judged to be outside the instructions for use (IFU) for conventional endografts, while amenable to treatment within the IFU for Ovation. METHODS AND RESULTS One hundred and twenty-two patients (78.65±7.67 years; 111 male) were enrolled. Patients were evaluated as being outside the IFU for standard endografts because of the absence of a suitable proximal aortic neck in 109 cases (89.3%), of inadequate access vessels in 13 (10.7%), or both in 111 (90.9%). Mean aneurysm (abdominal aortic aneurysm [AAA]) diameter was 52.96±10.1 mm; mean aortic neck length was 7.75±6.05 mm. Technical success (98.4%) was achieved in all but two patients due to a type Ia endoleak. At completion angiography, 15 (12.3%) patients presented a type II endoleak. All patients underwent 30-day follow-up. Primary clinical success at one month was 96.8%, assisted clinical success 98.4%. There were no type I endoleaks, while 12 (9.8%) type II endoleaks were still evident, in the absence of sac expansions. Two patients (1.6%) presented an asymptomatic limb occlusion. CONCLUSIONS Our experience suggests that, in a selected population of patients with challenging anatomy outside the IFU for conventional endografts, endovascular aneurysm repair (EVAR) using the Ovation stent graft can be performed safely with satisfactory immediate outcomes.
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Affiliation(s)
- Pasqualino Sirignano
- Vascular and Endovascular Surgery Division, Policlinico Umberto I, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Wassim Mansour
- Vascular and Endovascular Surgery Unit, Department of Surgery “Paride Stefanini”, Policlinico Umberto I of Rome, “Sapienza” University of Rome, Rome, Italy
| | - Laura Capoccia
- Vascular and Endovascular Surgery Unit, Department of Surgery “Paride Stefanini”, Policlinico Umberto I of Rome, “Sapienza” University of Rome, Rome, Italy
| | - Simone Cuozzo
- Vascular and Endovascular Surgery Unit, Department of Surgery “Paride Stefanini”, Policlinico Umberto I of Rome, “Sapienza” University of Rome, Rome, Italy
| | - Stefano Camparini
- Vascular and Endovascular Surgery Unit, Department of Thoraco-Vascular Surgery, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Gianmarco de Donato
- Vascular and Endovascular Surgery Unit, Department of Medicine, Surgery, and Neuroscience, University of Siena, Siena, Italy
| | - Nicola Mangialardi
- Department of Vascular Surgery, “San Camillo Forlanini” Hospital, Rome, Italy
| | - Sonia Ronchey
- Department of Vascular Surgery, “San Filippo Neri” Hospital, Rome, Italy
| | - Francesco Talarico
- Division of Vascular and Endovascular Surgery, Ospedale Civico, Palermo, Italy
| | - Carlo Setacci
- Vascular and Endovascular Surgery Unit, Department of Medicine, Surgery, and Neuroscience, University of Siena, Siena, Italy
| | - Francesco Speziale
- Vascular and Endovascular Surgery Unit, Department of Surgery “Paride Stefanini”, Policlinico Umberto I of Rome, “Sapienza” University of Rome, Rome, Italy
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Editor's Choice - Comprehensive Literature Review of Radiation Levels During Endovascular Aortic Repair in Cathlabs and Operating Theatres. Eur J Vasc Endovasc Surg 2020; 60:374-385. [PMID: 32682690 DOI: 10.1016/j.ejvs.2020.05.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 04/02/2020] [Accepted: 05/21/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Occupational exposure is a growing concern among the endovascular specialist community. Several types of imaging equipment are available, such as mobile C arms or hybrid rooms, and some have been shown to deliver higher levels of radiation. A literature review was conducted to identify studies reporting dose data during standard (EVAR) and complex abdominal aortic endovascular repair (fenestrated/branched EVAR [F/BEVAR]). METHODS A search of the MEDLINE and the Cochrane databases was performed by two independent investigators using the medical subject heading terms "aortic aneurysms", "radiation", and "humans" over a search period of 10 years. Studies with full text available in English and reporting radiation data independently from the imaging equipment type were included. Experimental studies were excluded. RESULTS The lowest dose-area product levels during EVAR and F/BEVAR were identified in hybrid rooms, while the highest were with fixed systems. When adherence to the as low as reasonably achievable principles was stipulated by the authors, dose reports tended to be among the lowest. Several studies, especially of F/BEVAR, report concerning levels of radiation for both patients and staff. CONCLUSION Modern imaging equipment type, team involvement with radiation management, and the support of recent imaging technologies such as fusion help to reduce the dose delivered during standard and complex EVAR. Investment in modern imaging technology should be considered in every centre providing endovascular management of aortic aneurysms.
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Karthaus EG, Vahl A, Elsman BHP, Wouters MWJM, de Borst GJ, Hamming JF. National Numbers of Secondary Aortic Reinterventions after Primary Abdominal Aortic Aneurysm Surgery from the Dutch Surgical Aneurysm Audit. Ann Vasc Surg 2020; 68:234-244. [PMID: 32335253 DOI: 10.1016/j.avsg.2020.04.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/29/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Long-term secondary aortic reinterventions (SARs) can be a sign of (lack of) effectiveness of abdominal aortic aneurysm (AAA) surgery. This study provides insight into the national number of SARs after primary AAA repair by endovascular aneurysm repair (EVAR) or by open surgical repair in the Netherlands. METHODS Observational study included all patients undergoing SAR between 2016 and 2017, registered in the compulsory Dutch Surgical Aneurysm Audit (DSAA). The DSAA started in 2013, SARs are registered from 2016. Characteristics of SAR and postoperative outcomes (mortality/complications) were analyzed, stratified by urgency of SAR. Data of SARs were merged with data of their preceded primary AAA repair, registered in the DSAA after January 2013. In these patients undergoing SAR, treatment characteristics of the preceded primary AAA repair were additionally described, with focus on differences between stent grafts. RESULTS Between 2016 and 2017, 691 patients underwent SAR, this concerned 9.3% of all AAA procedures (infrarenal/juxtarenal/suprarenal) in the Netherlands (77% elective/11% acute symptomatic/12% ruptured). Endoleak (60%) was the most frequent indication for SAR. SARs were performed with EVAR in 66%. Postoperative mortalities after SAR were 3.4%, 11%, and 29% in elective, acute symptomatic, and ruptured patients, respectively. In 26% (n = 181) of the patients undergoing SAR their primary AAA repair was performed after January 2013 and data of primary and SAR procedures could be merged. In 93% (n = 136), primary AAA repair was EVAR. Endografts primarily used were nitinol/polyester (62%), nitinol/polytetrafluoroethylene (8%), endovascular sealing (21%), and others (9%), compared with their national market share of 76% (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.38-0.71), 15% (OR, 0.50; CI, 0.29-0.89), 4.9% (OR, 5.04; CI, 3.44-7.38), and 4.1% (OR, 2.81; CI, 1.66-4.74), respectively. CONCLUSIONS In the Netherlands, about one-tenth of the annual AAA procedures concerns an SAR. A quarter of this cohort had an SAR within 1-5 years after their primary AAA repair. Most SARs followed after primary EVAR procedures, in which an overrepresentation of endovascular sealing grafts was seen. Postoperative mortality after SAR is comparable with primary AAA repair.
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Affiliation(s)
- Eleonora G Karthaus
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands; Dutch Institute for Clinical Auditing, Leiden, the Netherlands.
| | - Anco Vahl
- Department of Surgery, OLVG, Amsterdam, the Netherlands; Department of Clinical Epidemiology, OLVG, Amsterdam, the Netherlands
| | | | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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Prognosis review and time-to-event data meta-analysis of endovascular aneurysm repair outside versus within instructions for use of aortic endograft devices. J Vasc Surg 2020; 71:1415-1431.e15. [DOI: 10.1016/j.jvs.2019.08.247] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/06/2019] [Indexed: 01/08/2023]
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Nakai M, Ikoma A, Loffroy R, Kamisako A, Higashino N, Sonomura T. Endovascular management of endotension by graft reinforcement followed by direct sac embolization. MINIM INVASIV THER 2018; 28:234-240. [DOI: 10.1080/13645706.2018.1518918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Motoki Nakai
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama, Japan
| | - Akira Ikoma
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama, Japan
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, François-Mitterrand Teaching Hospital, University of Bourgogne, Dijon, France
| | - Atsufumi Kamisako
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama, Japan
| | - Nobuyuki Higashino
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama, Japan
| | - Tetsuo Sonomura
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama, Japan
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Nakai M, Ikoma A, Loffroy R, Midulla M, Kamisako A, Higashino N, Fukuda K, Sonomura T. Type II endoleak model creation and intraoperative aneurysmal sac embolization with n-butyl cyanoacrylate-lipiodol-ethanol mixture (NLE) in swine. Quant Imaging Med Surg 2018; 8:894-901. [PMID: 30505718 DOI: 10.21037/qims.2018.10.01] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The purpose of this study was to evaluate the feasibility of type II endoleak model creation and efficacy of intraoperative aneurysmal sac embolization using n-butyl-2-cyanoacrylate-lipiodol-ethanol mixture (NLE) for type II endoleak in swine. Methods In six swine (mean body weight 53.5 kg), abdominal aortic aneurysm (AAA) was created and then end-to-side anastomosis between the left renal artery and AAA sac was performed. And then, endovascular abdominal aortic aneurysm repair (EVAR) was performed, leading to creation of a type II endoleak model. As control group, EVAR without sac embolization was performed in two swine. In four swine, AAA sac was embolized using NLE immediately after EVAR via the microcatheter placed in AAA sac (NLE embolization group). Follow-up aortography was performed immediately and three days after the procedure, and then the aneurysms were extracted. Results The AAA sac and type II endoleak model were successfully created in all cases. In control group, type II endoleak persisted three days after the procedure. In NLE embolization group, endoleak disappeared immediately and three days after the procedure. In NLE embolization group, AAA sac was occupied with thrombus and embolic material. Inflammatory changes were recognized in aneurysmal sac wall in NLE embolization group. Conclusions This experimental study suggests that creation of a type II endoleak model in swine is feasible and that intraoperative AAA sac embolization with NLE during EVAR might reduce the occurrence of type II endoleak.
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Affiliation(s)
- Motoki Nakai
- Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Akira Ikoma
- Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
| | - Atsufumi Kamisako
- Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | | | - Kodai Fukuda
- Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Tetsuo Sonomura
- Department of Radiology, Wakayama Medical University, Wakayama, Japan
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Truong C, Kugler NW, Rossi PJ, Patel PJ, Hieb RA, Brown KR, Lewis BD, Seabrook G, Lee CJ. Sex-dependent outcomes following elective endovascular aortic repair. J Surg Res 2018; 229:177-185. [PMID: 29936987 DOI: 10.1016/j.jss.2018.03.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/01/2018] [Accepted: 03/13/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evidence has shown that women derive less benefit from endovascular aortic repair (EVAR) in large part due to more challenging aortoiliac anatomy. This study sought to examine whether sex-dependent outcomes exist following elective EVAR cases. METHODS An institutional retrospective review was performed on patients who underwent elective EVAR procedures between 2008 and 2014. Outcome data collected included procedural and hospital morbidity, mortality, and overall EVAR durability based on the incidence of unplanned graft-related secondary interventions (SIs) (e.g., open conversion, proximal or distal extensions, and coil embolizations). RESULTS One hundred eighty-one patients (150 men, 31 women) met the study inclusion criteria. Median follow-up was 40.3 mo. Women had more challenging anatomy compared to men including smaller overall iliac diameters (6.8 mm versus 8.0 mm, P < 0.001) and more severe iliac angulation (77% moderate to severe versus 44%, P < 0.001). Women had increased risk of postoperative complications compared to men (41.9% versus 11.3%, P = 0.003). There was no perioperative mortality in our series of elective EVAR cases. Median 5-y survival following EVAR was 64.4% for men and 76.3% for women (P = 0.599). Late SI rates following EVAR was 10.5% with 16 (10.7%) men and 3 (9.7%) women needing interventions (P = 0.870). Overall durability of EVAR extrapolated as time to SIs was 91% at 2 y and 85% at 5 y. Factors predisposing SIs were iliac tortuosity (P = 0.046), aortic neck angle (P = 0.022), and endoleak at the follow-up (P = 0.030). CONCLUSIONS In this study, immediate outcomes following EVAR were different between men and women, with women having increased rates of postoperative complications. Mortality and overall long-term durability of EVAR, however, were the same between sexes despite anatomical differences. EVAR durability was significantly dependent on the severity of iliac tortuosity, aortic neck angulation, and presence of endoleak at the follow-up.
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Affiliation(s)
- Connie Truong
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nathan W Kugler
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Peter J Rossi
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Parag J Patel
- Division of Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert A Hieb
- Division of Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kellie R Brown
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Brian D Lewis
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gary Seabrook
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cheong J Lee
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Beckerman WE, Tadros RO, Faries PL, Torres M, Wengerter SP, Vouyouka AG, Lookstein RA, Marin ML. No major difference in outcomes for endovascular aneurysm repair stent grafts placed outside of instructions for use. J Vasc Surg 2016; 64:63-74.e2. [DOI: 10.1016/j.jvs.2016.01.034] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
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Prophylactic Intraoperative Embolization of Abdominal Aortic Aneurysm Sacs Using N -Butyl Cyanoacrylate/Lipiodol/Ethanol Mixture with Proximal Neck Aortic Balloon Occlusion during Endovascular Abdominal Aortic Repair. J Vasc Interv Radiol 2016; 27:954-60. [DOI: 10.1016/j.jvir.2016.03.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 03/19/2016] [Accepted: 03/19/2016] [Indexed: 11/18/2022] Open
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Nakai M, Ikoma A, Sato H, Sato M, Nishimura Y, Okamura Y. Risk factors associated with late aneurysmal sac expansion after endovascular abdominal aortic aneurysm repair. Diagn Interv Radiol 2016; 21:195-201. [PMID: 25858524 DOI: 10.5152/dir.2014.14308] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to identify the risk factors associated with late aneurysmal sac expansion after endovascular abdominal aortic aneurysm repair (EVAR). METHODS We retrospectively reviewed contrast-enhanced computed tomography (CT) images of 143 patients who were followed for ≥6 months after EVAR. Sac expansion was defined as an increase in sac diameter of 5 mm relative to the preoperative diameter. Univariate and multivariate analyses were performed to identify associated risk factors for late sac expansion after EVAR from the following variables: age, gender, device, endoleak, antiplatelet therapy, internal iliac artery embolization, and preprocedural variables (aneurysm diameter, proximal neck diameter, proximal neck length, suprarenal neck angulation, and infrarenal neck angulation). RESULTS Univariate analysis revealed female gender, endoleak, aneurysm diameter ≥60 mm, suprarenal neck angulation >45°, and infrarenal neck angulation >60° as factors associated with sac expansion. Multivariate analysis revealed endoleak, aneurysm diameter ≥60 mm, and infrarenal neck angulation >60° as independent predictors of sac expansion (P < 0.05, for all). CONCLUSION Our results suggest that patients with small abdominal aortic aneurysms (<60 mm) and infrarenal neck angulation ≤60° are more favorable candidates for EVAR. Intraprocedural treatments, such as prophylactic embolization of aortic branches or intrasac embolization, may reduce the risk of sac expansion in patients with larger abdominal aortic aneurysms or greater infrarenal neck angulation.
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Affiliation(s)
- Motoki Nakai
- Department of Radiology, Wakayama Medical University, Wakayama, Japan.
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Ikoma A, Nakai M, Sato M, Sato H, Minamiguchi H, Sonomura T, Nishimura Y, Okamura Y. Systolic Sac Pressure Index for the Prediction of Persistent Type II Endoleak for 12 Months After Endovascular Abdominal Aortic Aneurysm Repair. Cardiovasc Intervent Radiol 2015; 39:522-9. [PMID: 26353899 DOI: 10.1007/s00270-015-1191-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 04/19/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To assess the relationship between the systolic sac pressure index (SPI) and the presence of endoleaks 12 months after endovascular abdominal aortic aneurysm repair (EVAR). MATERIALS AND METHODS We performed a single-center prospective trial of consecutively treated patients. SPI (calculated as systolic sac pressure/systolic aortic pressure) was measured by catheterization immediately after EVAR. Contrast-enhanced computed tomography was scheduled 12 months after EVAR to detect possible endoleaks. RESULTS Data were available for 34 patients who underwent EVAR for an AAA. Persisting type II endoleak was found in 8 patients (endoleak-positive group) but not in the other 26 patients (endoleak-negative group). The mean ± standard deviation SPI was significantly greater in the endoleak-positive group than in the endoleak-negative group (0.692 ± 0.048 vs. 0.505 ± 0.081, respectively; P = .001). Receiver-operating characteristic curve analysis revealed that an SPI of 0.638 was the optimum cutoff value for predicting a persistent endoleak at 12 months with high accuracy (0.971; 33/34), sensitivity (1.00), and specificity (0.962) values. The mean change in AAA diameter was -4.28 ± 5.03 mm and 2.22 ± 4.54 mm in patients with SPI of <0.638 or ≥0.638, respectively (P = .002). CONCLUSION Patients with an SPI of ≥0.638 immediately after EVAR were more likely to have a persistent type II endoleak at 12 months with an accuracy of 0.971, and showed increases in aneurysm sac diameter compared with patients with an SPI of <0.638.
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Affiliation(s)
- Akira Ikoma
- Departments of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan.
| | - Motoki Nakai
- Departments of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan.
| | - Morio Sato
- Departments of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan.
| | - Hirotatsu Sato
- Departments of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan.
| | - Hiroki Minamiguchi
- Departments of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan.
| | - Tetsuo Sonomura
- Departments of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan.
| | - Yoshiharu Nishimura
- Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan.
| | - Yoshitaka Okamura
- Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, 641-8510, Japan.
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8-Year Long-Term Outcome Comparison: Two Ways to Exclude the Internal Iliac Artery during Endovascular Aorta Repair (EVAR) Surgery. PLoS One 2015; 10:e0130586. [PMID: 26193113 PMCID: PMC4507853 DOI: 10.1371/journal.pone.0130586] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 05/22/2015] [Indexed: 02/05/2023] Open
Abstract
Purpose To evaluate the 8-year long-term outcome after internal iliac artery (IIA) coverage with or without embolization in EVAR. Patients and Methods From January 2006 to December 2013, abdominal aortic aneurysm (AAA) subjects that underwent EVAR and IIA exclusion were recruited and analyzed retrospectively. All the subjects were divided into group A or B based on the presence or absence of intraoperative IIA embolization before coverage (group A: without embolization; group B: with embolization). The 30-day mortality, stent patency, and the incidences of endoleaks and ischemia of the buttocks and lower limbs were compared. The follow-up period was 96 months. Result There were 137 subjects (A: 74 vs. B: 63), 124 male (91.1%) and 13 female (9.5%), with a mean age of 71.6 years. There were no significant differences in the early outcomes of intraoperative blood loss (87.23±14.07 ml; A: 86.53±9.57 ml vs. B: 88.06±18.04 ml, p = .545) and surgery time (87.13±9.25 min; A: 85.99±7.07 min vs. B: 88.48±11.19 min, p = .130). However, there were significant differences in contrast consumption (65.18±9.85 ml; A: 61.89±7.95 ml vs. B: 69.05±10.50 ml, p<.001) and intraoperative X-ray time (5.9±0.86 min; A: 5.63±0.49 min vs. B: 6.22±1.07 min, P<.001). The 30-day mortality was approximately 0.73%. In the follow-up analysis, no significant differences were identified in the incidence of endoleak (22 subjects; type I: A: 2 vs. B: 2, p = 1.000; type II: A: 8 vs. B: 4, p = .666; type III: A: 4 vs. B: 3, p = 1.000), occlusion (5 subjects; 4.35%; A: 1 vs. B: 4, p = .180), or ischemia (9 subjects; 7.83%; A: 3 vs. B: 6, p = .301). In the analysis of group B, although there were no significant differences between subjects with unilateral and bilateral IIA embolization, but longer hospital stays were required (P<.001), and a more severe complication (skin and gluteus necrosis) occurred in 1 subject with bilateral IIA embolization. Conclusion IIA could be excluded during EVAR. IIA coverage without embolization had a good surgical and prognostic outcome, and this procedure was not different significantly from coverage with embolization in terms of endoleaks, patency and ischemia.
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Spanos K, Karathanos C, Saleptsis V, Giannoukas AD. Systematic review and meta-analysis of migration after endovascular abdominal aortic aneurysm repair. Vascular 2015; 24:323-36. [DOI: 10.1177/1708538115590065] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim To identify patients who are under higher threat for migration because of an old generation stent graft application. Methods A systematic review and meta-analysis of the literature was undertaken to identify all studies which included older generation endografts and data reporting on graft migration after EVAR. Outcome data were pooled and combined, and were calculated using fixed or random effects models. Results From 2000 to 2014, 22 retrospective studies were identified reporting on stent- graft migration after EVAR (8.6%). From those patients, 39% received re-intervention with the mean time of identification ranging from 12 to 36 months. Six of these retrospective nonrandomized studies were eligible for meta-analysis. AAA diameter (AAA diameter: 0.719 mm; 95% confidence interval [CI]: 0.00065–1.4384 mm; p = 0.00497) and neck length (neck length: 4.36 mm; 95% CI: 1.3277–7.394; p = 0.0048) were the only significant factors associated with stent- graft migration. Neck diameter and neck angulation did not have any important influence on stent-graft migration. Conclusions Patients with large AAA and short necks who were treated with older generation stent grafts such as AneurX and Talent are in higher risk for endograft migration than others. Stent- graft migration consists of an insidious and underestimated threat.
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Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Christos Karathanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Vasileios Saleptsis
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Utility of 99mTc–Human Serum Albumin Diethylenetriamine Pentaacetic Acid SPECT for Evaluating Endoleak After Endovascular Abdominal Aortic Aneurysm Repair. AJR Am J Roentgenol 2015; 204:189-96. [DOI: 10.2214/ajr.13.12383] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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de Vries JPP, Ouriel K, Mehta M, Varnagy D, Moore WM, Arko FR, Joye J, Jordan WD, Jordan WD, Paul de Vries J, Joye J, Eckstein H, van Herwaarden J, Arko FR, Bove P, Bohannon W, Fioole B, Setacci C, Resch T, Riambau V, Scheinert D, Clair D, Moursi M, Farber M, Tessarek J, Torsello G, Fillinger M, Glickman M, Henretta J, Hodgson K, Jim J, Katzen B, Lipsitz E, Cox M, Naslund T, Ramaiah V, Schermerhorn M, Schneider P, Starnes BW, Donayre C, Mehta M, Zipfel B, Malhotra N, Varnagy D, Moore W, Cheshire N, Bicknell C, Back M, Muhs B, Malas MB, Hussain S, Gupta N, Bockler D, Verhoeven E, Reijnen M. Analysis of EndoAnchors for endovascular aneurysm repair by indications for use. J Vasc Surg 2014; 60:1460-7.e1. [DOI: 10.1016/j.jvs.2014.08.089] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 08/12/2014] [Indexed: 11/28/2022]
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Scali ST, McNally MM, Feezor RJ, Chang CK, Waterman AL, Berceli SA, Huber TS, Beck AW. Elective endovascular aortic repair conversion for type Ia endoleak is not associated with increased morbidity or mortality compared with primary juxtarenal aneurysm repair. J Vasc Surg 2014; 60:286-294.e1. [PMID: 24684769 PMCID: PMC4143905 DOI: 10.1016/j.jvs.2014.02.046] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 02/18/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Type Ia endoleak after endovascular aortic repair (EVAR) can be a challenging complication to manage, and due to concerns regarding morbidity and mortality of open surgical conversion (OSC), reports of complex endoluminal salvage techniques are increasing. Despite development of these endovascular remedial strategies, many patients ultimately require OSC. The purpose of this analysis was to outcomes of elective OSC for type Ia endoleak and compare them with elective primary open juxtarenal aneurysm repair (OJAR) to determine if these concerns are warranted. METHODS From 2000 to 2012, 54 patients underwent EVAR OSC at median time of 27 months (interquartile range, 9-55 months). Indications included endograft thrombosis in 2 (4%), intraoperative EVAR failure in 3 (6%), rupture in 5 (9%), graft infection in 6 (11%), and type Ia endoleak in 25 (all: 38 [70%]). Because many OSCs are performed for emergency indications without endovascular options, we chose elective type Ia endoleak patients as our study group. These 25 patients were compared with an elective OJAR cohort matched by anatomy and comorbidities. Primary end points were 30-day and 1-year mortality. Secondary end points included early complications, cross-clamp time, procedure time, blood loss, and length of stay. RESULTS Demographic and comorbidity data in the OSC and OJAR groups did not differ, with the exception that OJAR patients presented with smaller aneurysm diameter and a higher rate of chronic obstructive pulmonary disease (P = .03). OSC patients more frequently underwent a nontube graft repair (OSC, n = 20 [80%] vs OJAR, n = 6 [24%]; P = .0002), required longer procedure times (P = .03), and received more plasma transfusions (P = .03). The 30-day mortality was 4% in both groups (observed difference in rates, 0%; 95% confidence interval for difference in mortality rates, -14.0% to 14.0%; P = 1). A similar rate of major complications occurred (OSC, n = 9 [36%] vs OJAR, n = 8 [32%]; P = 1). One-year survival was 83% in OSC and 91% in OJAR (observed difference, 7%; 95% confidence interval, -15% to 29%; P = .65). CONCLUSIONS Despite many advances in EVAR technology, the need for OSC persists and will likely become more common as older-generation devices fail or providers attempt EVAR in more anatomically complex patients. Elective OSC for type Ia endoleak can be technically challenging but is not associated with increased morbidity or mortality compared with OJAR in appropriately selected patients. These results should be considered before pursuing complex endovascular remediation of EVAR failures.
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Affiliation(s)
- Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
| | - Michael M McNally
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Robert J Feezor
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Catherine K Chang
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Alyson L Waterman
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
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Ikoma A, Nakai M, Sato M, Sato H, Takeuchi H, Tanaka F, Sanda H, Nakata K, Minamiguchi H, Sonomura T, Nishimura Y, Okamura Y. Changes in inflammatory, coagulopathic, and fibrinolytic responses after endovascular repair of an abdominal aortic aneurysm: relationship between fibrinogen degradation product levels and endoleaks. Jpn J Radiol 2014; 32:347-55. [DOI: 10.1007/s11604-014-0314-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 04/01/2014] [Indexed: 10/25/2022]
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