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Sirignano P, Mangialardi N, Nespola M, Aloisi F, Orrico M, Ronchey S, Del Porto F, Taurino M. Incidence and Fate of Refractory Type II Endoleak after EVAR: A Retrospective Experience of Two High-Volume Italian Centers. J Pers Med 2022; 12:339. [PMID: 35330339 PMCID: PMC8954032 DOI: 10.3390/jpm12030339] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: The aim of the present study is to report the outcome of patients presenting an isolated type II endoleak (TIIEL) requiring reintervention and to identify clinical and anatomical characteristics potentially implicated in refractory TIIEL occurrence and fate. Materials and Methods: A multicenter retrospective study on TIIEL requiring reintervention was conducted between January 2003 and December 2020. Demographic and clinical characteristics, procedural technical aspects, reinterventions, and outcomes were recorded. TIIEL determining sac expansion greater than 10 mm underwent a further endovascular procedure aiming to exclude aneurismal sac. Redo endovascular procedures were performed via endoleak nidus direct embolization and/or aortic side branches occlusion. TIIELs responsible for persisting aneurysmal sac perfusion 6 months after redo endovascular procedures were classified as “refractory” and submitted to open conversion. Results: A total of 102 TIIEL requiring reintervention were included in the final analysis. Eighty-eight (86.27%) patients were male, the mean age was 77.32 ± 8.08 years, and in 72.55% of cases the American Society of Anaesthesiologists (ASA) class was ≥3. The mean aortic diameter was 64.7 ± 14.02 mm, half of treated patients had a patent inferior mesenteric artery (IMA), and 44.11% ≥ 3 couples of patent lumbar arteries (LA). In 49 cases (48.03%) standard endovascular aneurysm repair (EVAR) procedure was completed without adjunctive maneuvers. All enrolled patients were initially submitted to a further endovascular procedure once TIIEL requiring reintervention was diagnosed; 57 patients underwent LAs or IMA embolization (55.87%), 42 transarterial aneurismal sac embolization (41.17%), and three (2.96%) laparoscopic ostial ligations of the inferior mesenteric artery. During a mean follow-up of 15.22 ± 7.57 months (7−48), a redo endovascular approach was able to ensure complete sac exclusion in 52 cases, while 50 patients presented a still evident refractory TIIEL and therefore a surgical conversion or semiconversion was conducted. At the univariate analysis refractory TIIEL patients were significantly different from those who did not develop the complication in terms of preoperative clinical, morphological characteristics, and initial EVAR procedures: coronary artery disease occurrence (p = 0.005, OR: 3.18, CI95%: 1.3−7.2); preoperative abdominal aortic aneurysm (AAA) sac diameter (p = 0.0055); IMA patency (p = 0.016, OR: 2.64, CI95%: 1.18−5.90); three or more patent LAs; isolated standard EVAR without adjunctive procedures (p > 0.0001; OR: 9.48, CI95%: 3.84−23.4). Conclusions: Our experience seems to demonstrate that it is reasonable to try to preoperatively identify those patients who will develop a refractory TIIEL after EVAR and those with a TIIEL requiring reintervention for whom a simple endovascular redo will not be enough, needing surgical conversion.
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Affiliation(s)
- Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Sant’Andrea Hospital, Department of Surgery Paride Stefanini, Sapienza University of Rome, 00189 Rome, Italy
| | - Nicola Mangialardi
- Department of Vascular Surgery, Ospedale San Camillo-Forlanini, 00152 Rome, Italy; (N.M.); (M.O.); (S.R.)
| | - Martina Nespola
- Vascular and Endovascular Surgery Unit, Sant’Andrea Hospital, Department of Molecular and Clinical Medicine, Sapienza University of Rome, 00189 Rome, Italy; (M.N.); (F.A.); (M.T.)
| | - Francesco Aloisi
- Vascular and Endovascular Surgery Unit, Sant’Andrea Hospital, Department of Molecular and Clinical Medicine, Sapienza University of Rome, 00189 Rome, Italy; (M.N.); (F.A.); (M.T.)
| | - Matteo Orrico
- Department of Vascular Surgery, Ospedale San Camillo-Forlanini, 00152 Rome, Italy; (N.M.); (M.O.); (S.R.)
| | - Sonia Ronchey
- Department of Vascular Surgery, Ospedale San Camillo-Forlanini, 00152 Rome, Italy; (N.M.); (M.O.); (S.R.)
| | - Flavia Del Porto
- Internal Medicine Unit, Sant’Andrea Hospital, Department of Molecular and Clinical Medicine, Sapienza University of Rome, 00189 Rome, Italy;
| | - Maurizio Taurino
- Vascular and Endovascular Surgery Unit, Sant’Andrea Hospital, Department of Molecular and Clinical Medicine, Sapienza University of Rome, 00189 Rome, Italy; (M.N.); (F.A.); (M.T.)
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Rokosh RS, Chang H, Butler JR, Rockman CB, Patel VI, Milner R, Jacobowitz GR, Cayne NS, Veith F, Garg K. Prophylactic Sac Outflow Vessel Embolization is Associated with Improved Sac Regression in Patients Undergoing Endovascular Aortic Aneurysm Repair. J Vasc Surg 2021; 76:113-121.e8. [PMID: 34923066 DOI: 10.1016/j.jvs.2021.11.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 11/14/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Type II endoleaks (T2E), commonly identified after endovascular aneurysm repair (EVAR), have been associated with late endograft failure and secondary rupture. Number and size of patent aortic aneurysm sac outflow vessels, namely the inferior mesenteric, lumbar, and accessory renal arteries, have been implicated as known risk factors for persistent T2E. Given technical challenges associated with post-EVAR embolization, prophylactic embolization of aortic aneurysm sac outflow vessels has been advocated to prevent T2E; however, current evidence is limited. We sought to examine the effect of concomitant prophylactic aortic aneurysm sac outflow vessels embolization in patients undergoing EVAR. METHODS Patients 18 and older in the SVS Vascular Quality Initiative database who underwent elective EVAR for intact aneurysms between January 2009 and November 2020 were included. Patients with history of prior aortic repair and those without available follow-up data were excluded. Patient demographics, operative characteristics, and outcomes were analyzed by group: EVAR with or without prophylactic sac outflow vessel embolization (emboEVAR). Outcomes of interest were rates of in-hospital postoperative complications, incidence of aneurysmal sac regression (≥5mm) and T2E, and rates of re-intervention in follow-up. RESULTS 15060 patients were included: 272 had emboEVAR and 14788 had EVAR alone. There was no significant difference between groups in terms of age, comorbidities, or anatomic characteristics including mean maximum preoperative aortic diameter (5.5 vs. 5.6 cm, p=0.48). emboEVAR was associated with significantly longer procedural times (148 vs. 124 minutes, p<0.0001), prolonged fluoroscopy (32 vs. 23 minutes, p<0.0001), increased contrast use (105 vs. 91 mL, p<0.0001), without significant reduction in T2E at case completion (17.7% vs. 16.3%, p=0.54). Incidence of postoperative complications (3.7% vs. 4.6%, p=0.56), index hospitalization reintervention rates (0.7% vs. 1.3%, p=0.59), length of stay (1.8 vs. 2 days, p=0.75), and thirty-day mortality (0% vs. 0%, p=1) were similar between groups. In mid-term follow-up (14.6±6.2 months), the emboEVAR group had a significantly greater mean reduction in maximum aortic diameter (0.69 vs. 0.54 cm, p=0.006) with a higher proportion experiencing sac regression ≥5 mm (53.5% vs. 48.7%). Re-intervention rates were similar between groups. On multivariable analysis, prophylactic aortic aneurysm sac outflow vessel embolization (OR 1.34, CI 1.04-1.74, p=0.024) was a significant independent predictor of sac regression. CONCLUSIONS Prophylactic sac outflow vessel embolization can be performed safely for patients with intact aortic aneurysms undergoing elective EVAR without significant associated perioperative morbidity or mortality. emboEVAR is associated with significant sac regression compared to EVAR alone in mid-term follow-up. Although there was not a decrease in the incidence of T2E, this technique shows promise and future efforts should focus on identifying a subset of aneurysm and outflow branch characteristics that will benefit from concomitant selective versus complete prophylactic sac outflow vessel embolization.
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Affiliation(s)
- Rae S Rokosh
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY; Division of Vascular & Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Heepeel Chang
- Westchester Medical Center, New York Medical College, Valhalla, NY
| | | | - Caron B Rockman
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Virendra I Patel
- Division of Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Ross Milner
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago, Chicago, IL
| | - Glenn R Jacobowitz
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Neal S Cayne
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Frank Veith
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY.
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Natural history of isolated type II endoleaks in patients treated by fenestrated-branched endovascular repair for pararenal and thoracoabdominal aortic aneurysms. J Vasc Surg 2020; 72:44-54. [DOI: 10.1016/j.jvs.2019.09.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/13/2019] [Indexed: 11/21/2022]
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Mastrorilli D, Mezzetto L, D'Oria M, Simoncini F, Bergamaschi G, Veraldi GF. Early and Late Outcomes of Ultrasound-Guided Direct Transabdominal Embolization of Isolated Type 2 Endoleaks after Endovascular Aortic Repair. Ann Vasc Surg 2020; 68:252-260. [PMID: 32339679 DOI: 10.1016/j.avsg.2020.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 04/09/2020] [Accepted: 04/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this study is to report the early and late outcomes of ultrasound-guided direct transabdominal embolization (UGDTE) of isolated type 2 endoleak (T2EL) after endovascular aneurysm repair (EVAR). METHODS Forty-two consecutive T2EL patients were treated between February 2000 and September 2017 by UGDTE after previous EVAR. During the study period, UGDTE was the firs-line technique implemented for treatment of T2EL. All procedures were carried out using the same predefined technique. Aneurysm sac size change from the index treatment, freedom from recurrent endoleak after treatment, demographics, risk factors, and procedural factors were analyzed with univariate analysis. RESULTS During the study interval, 612 patients underwent standard EVAR for abdominal aortic aneurysm treatment and 111 (18.2%) developed an isolated T2EL. Of these, 42 (6.8%) consecutive patients were deemed suitable and treated with UDGT. Median imaging follow-up duration was 18.7 months. Median fluoroscopic and procedure times were 7 and 58 minutes, respectively. The rate of immediate technical success was 100%. Ten patients (23.8%) underwent reintervention for recurrent T2EL. Freedom from reintervention for T2EL at 1, 2, and 4 years was 81%, 78%, and 71%. No aneurysm-related mortality occurred during the follow-up period. CONCLUSIONS The use of UGDTE for treatment of isolated T2EL after EVAR is a safe and feasible technique when performed by experienced operators, resulting in high technical success and low complication rates in selected patients. Although being effective in obtaining T2EL exclusion, up to one-third of the patients may require repeat intervention during long-term follow-up. Therefore, lifelong surveillance after the procedure is recommended.
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Affiliation(s)
- Davide Mastrorilli
- Department of Vascular Surgery, University Hospital of Verona, University of Verona School of Medicine, Verona, Italy.
| | - Luca Mezzetto
- Department of Vascular Surgery, University Hospital of Verona, University of Verona School of Medicine, Verona, Italy
| | - Mario D'Oria
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Fabio Simoncini
- Department of Vascular Surgery, University Hospital of Verona, University of Verona School of Medicine, Verona, Italy
| | - Gastone Bergamaschi
- Department of Surgery, Gerolamo Fracastoro Hospital, San Bonifacio, Verona, Italy
| | - Gian Franco Veraldi
- Department of Vascular Surgery, University Hospital of Verona, University of Verona School of Medicine, Verona, Italy
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D'Oria M, Mastrorilli D, Ziani B. Natural History, Diagnosis, and Management of Type II Endoleaks after Endovascular Aortic Repair: Review and Update. Ann Vasc Surg 2020; 62:420-431. [PMID: 31376537 DOI: 10.1016/j.avsg.2019.04.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/02/2019] [Accepted: 04/28/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Mayo Clinic Gonda Vascular Center, Rochester, MN; Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy.
| | - Davide Mastrorilli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Barbara Ziani
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
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Fujii T, Banno H, Kodama A, Sugimoto M, Akita N, Tsuruoka T, Sakakibara M, Komori K. Aneurysm Sac Thrombus Volume Predicts Aneurysm Expansion with Type II Endoleak After Endovascular Aneurysm Repair. Ann Vasc Surg 2019; 66:85-94.e1. [PMID: 31863957 DOI: 10.1016/j.avsg.2019.11.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/21/2019] [Accepted: 11/30/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Several studies have analyzed risk factors that may influence the incidence of type II endoleak with sac expansion after endovascular aneurysm repair (EVAR). However, the impact of intraluminal thrombus volume on the incidence of sac expansion with type II endoleak requires further analysis. This study examined the correlation between preoperative intraluminal thrombus and the incidence of type II endoleak and late sac expansion by measuring the thrombus volume. METHODS Between June 2007 and March 2014, 423 patients underwent EVAR at our institution. Two hundred and eighty patients with preoperative and postoperative computed tomography angiography (CTA) were included in this study. Data were collected prospectively and supplemented with a retrospective review of the medical records and radiologic images, and demographic and clinical characteristic profiles were collected. Logistic regression and Cox regression analyses were used to assess each variable's association with the incidences of persistent or new endoleak and sac expansion. RESULTS Of the 280 patients, 46.7% (131 patients) had persistent type II endoleak, and 19.6% (55 patients) had persistent type II endoleak with significant sac expansion (≥5 mm). The mean follow-up duration was 60 months (interquartile range, 24-72 months). Cox regression analysis showed that older age (P = 0.001), intraluminal thrombus volume ratio (thrombus volume [T vol]/aortic aneurysm volume [A vol]) (P = 0.042) and IMA diameter (P = 0.004) were significant predictors of the incidence of sac expansion with persistent or new type II endoleak. The receiver operating characteristic curve analysis revealed a cutoff of 51% T vol/A vol (area under the curve [AUC]: 0.59) and 2.9 mm (area under the curve [AUC]: 0.60). The rate of freedom from sac expansion (≥5 mm) during followup was significantly higher in patients with ≥51% T vol/A vol than in those with a lower T vol/A vol (P = 0.010). CONCLUSIONS Preoperative sac thrombus volume, IMA diameter, and older age predict the incidence of aneurysm expansion with type II endoleak after EVAR.
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Affiliation(s)
- Takayuki Fujii
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Hiroshi Banno
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayuki Sugimoto
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naohiro Akita
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Tsuruoka
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masashi Sakakibara
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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