A single-institution experience with the AneuRx Stent Graft for endovascular repair of abdominal aortic aneurysm

Occurrence and outcomes of type 3 endoleaks in endovascular aortic repair within the Vascular Quality Initiative database

Objectives

Type 3 endoleaks (T3ELs) represent a lack of aneurysm protection from systemic pressure. Previous studies have found a ~2% incidence of T3EL after standard infrarenal endovascular aneurysm repair (EVAR); however, no prior studies with new-generation devices have been able to determine an association between T3EL and clinical outcomes. Here we examine T3EL within the Society for Vascular Surgery Vascular Quality Initiative (VQI) to define rates of occurrence, rates and modes of reintervention, and clinical consequences of these endoleaks.

Design and setting

Participants receiving infrarenal EVAR in the VQI from January 2003 to September 2018 were analyzed in a retrospective cohort study.

Participants

Of 42 246 entries in the EVAR procedural registry, 41 604 had complete procedural information and were included in analysis. Of these, 36 082 had long-term follow-up, and 26 422 had follow-up (9-21 months per VQI reporting standards) with complete endoleak data recorded.

Interventions

All patients included in this study underwent an infrarenal EVAR.

Results

Within the VQI database, the rate of T3EL in infrarenal EVAR during index hospitalization was 0.37% (n=157/41 604), of which 85% were due to midgraft separation and 15% were due to fabric disruptions. Out of the 157 index hospitalization T3ELs, 4.5% (n=7) received procedural reintervention during that hospitalization, which accounted for 1% of all index hospitalization reinterventions. During the 21-month follow-up, the rate of incident T3EL was 0.7% (n=205/26 422), which accounted for 5% of all endoleaks seen during follow-up. Reinterventions for incident T3EL at follow-up were done in 30 patients (rate 0.1%), which accounted for 9% of endoleak reinterventions and 3.3% of all reinterventions. The presence of incident T3EL found during follow-up was associated with a significant decrease in 5-year survival (74% vs 80%, respectively; p=0.041) in Kaplan-Meier analysis.

Conclusion

T3ELs rates at placement and follow-up remain low; however, the majority reported in long-term follow-up are incident and these incident endoleaks are associated with decreased survival in EVAR.

Closure of an unusual morphology patent ductus arteriosus with a covered stent in a dog

Patent ductus arteriosus (PDA) with unusual morphology was diagnosed in a 3-year-old German shepherd presented for exercise intolerance. Two interventional PDA closure procedures with various Amplatzer devices and one surgical ligation were attempted to close the PDA. However, PDA closure failed with both methods due to the unusual morphology and the severe enlarged ductus ampulla. Therefore, the patient underwent an aortic covered stent placement, and successful closure of the PDA was achieved. Eight months after the procedure, the dog was free of clinical signs and no residual flow was identified through the PDA on transthoracic echocardiography. Moreover, computed tomography angiography demonstrated correct stent positioning, with no evidence of thrombus formation, damage to the stent, nor any aortic wall abnormalities. Aortic covered stent placement is a viable option in dogs with unusual PDA morphology.

Quality improvement guidelines for imaging detection and treatment of endoleaks following endovascular aneurysm repair (EVAR)

Major concerns after aortic aneurysm repair are caused by the presence of endoleaks, which are defined as persistent perigraft flow within the aortic aneurysm sac. Diagnosis of endoleaks can be performed with various imaging modalities, and indications for treatment are based on further subclassifications. Early detection and correct classification of endoleaks are crucial for planning patient management. The vast majority of endoleaks can be treated successfully by interventional means. Guidelines for Imaging Detection and Treatment of endoleaks are described in this article.

AAA stent-grafts: past problems and future prospects

Endovascular aneurysm repair (EVAR) has quickly gained popularity for infrarenal abdominal aortic aneurysm repair during the last two decades. The improvement of available EVAR devices is critical for the advancement of patient care in vascular surgery. Problems are still associated with the grafts, many of which can necessitate the conversion of the patient to open repair, or even result in rupture of the aneurysm. This review attempts to address these problems, by highlighting why they occur and what the failings of the currently available stent grafts are, respectively. In addition, the review gives critical appraisal as to the novel methods required for dealing with these problems and identifies the new generation of stent grafts that are being or need to be designed and constructed in order to overcome the issues that are associated with the existing first- and second-generation devices.

Syndecan-4 mediates macrophage uptake of group V secretory phospholipase A2-modified LDL

We previously reported that LDL modified by group V secretory phospholipase A2 (GV-LDL) promotes macrophage foam cell formation through a mechanism independent of scavenger receptors SR-A and CD36, and dependent on cellular proteoglycans. This study investigates the role of syndecans, a family of cell surface proteoglycans known to mediate endocytosis through macropinocytosis, in macrophage uptake of GV-LDL. LY 294002, a phosphatidylinositol 3-kinase inhibitor, significantly reduced internalization of (125)I-labeled GV-LDL in J-774 macrophages, consistent with a macropinocytic uptake pathway. Using small, interfering RNA-directed gene silencing, we demonstrated a direct relationship between (125)I-labeled GV-LDL binding and the level of syndecan-3 and syndecan-4 expression in J-774 cells. However, (125)I-labeled GV-LDL uptake was significantly reduced only when syndecan-4 expression was suppressed. Peritoneal macrophages from syndecan-4-deficient mice exhibited markedly reduced uptake of fluorescently labeled GV-LDL compared with wild-type cells. Furthermore, cholesteryl ester accumulation induced by GV-LDL was dependent on syndecan-4 expression. Syndecan-4 expression and GV-LDL binding were significantly increased in J-774 cells treated with lipopolysaccharide, suggesting that GV-LDL uptake via this pathway may be enhanced during inflammation. Taken together, our data point to a novel role for syndecan-4 in mediating the uptake of GV-LDL, a process implicated in atherosclerotic lesion progression.