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Ding Y, Zhou M, Li X, Xie T, Zhou Z, Fang S, Shi Z, Fu W. The real-world incidence and predictors of sac regression in patients with infrarenal abdominal aortic aneurysm after standard EVAR. Asian J Surg 2024:S1015-9584(24)00195-7. [PMID: 38403543 DOI: 10.1016/j.asjsur.2024.01.141] [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: 11/05/2023] [Revised: 01/21/2024] [Accepted: 01/26/2024] [Indexed: 02/27/2024] Open
Abstract
OBJECTIVE Sac regression (SR) is a surrogate marker of satisfied endovascular aneurysm repair (EVAR). This research aims to investigate the incidence and predictors of SR in a Chinese population. DESIGN Single centre retrospective cohort study. METHODS Consecutive patients with infrarenal abdominal aortic aneurysms (AAAs) who underwent standard EVAR were retrospectively reviewed. SR was defined as sac shrinkage > 5 mm on computed tomography images, while major SR (MaSR) was ≥ 10 mm sac shrinkage. The cumulative rate was calculated by Kaplan-Meier analysis and predictors were identified by the Cox regression model. RESULTS A total of 469 patients (median age, 71 years old) were included. The majority of them (86.6 %) were male. With a median time of 13.6 months, SR was detected in 129 (27.5 %) patients after the index EVAR. Compared with never smokers, current smokers were more likely to experience SR (adjusted HR 2.630, p < .001), while former smokers did not show any significant difference. Multivariate Cox regression also showed that maximal aneurysm diameter (adjusted HR 1.012, p = 0.035) and female (adjusted HR 1.675, p = .045) were independent predictors of SR. A total of 51 (10.9 %) patients had MaSR at a median time of 15.4 months after EVAR. In multivariate analysis, maximal aneurysm diameter and Zenith stent graft were independently associated with MaSR. CONCLUSION In Chinese population, the incidence of SR and MaSR was 27.5 % and 10.9 % after EVAR, respectively. Maximal aneurysm diameter and female were independent predictors of SR. Compared with never smokers, it was more likely to have SR in current smokers.
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Affiliation(s)
- Yong Ding
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
| | - Min Zhou
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
| | - Xu Li
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
| | - Tianchen Xie
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
| | - Zhenyu Zhou
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
| | - Sheng Fang
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
| | - Zhenyu Shi
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
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Nocun W, Muscogliati R, Al-Tawil M, Jubouri M, Alsmadi AS, Surkhi AO, Bailey DM, Williams IM, Bashir M. Impact of patient demographics and intraoperative characteristics on abdominal aortic aneurysm sac following endovascular repair. Asian Cardiovasc Thorac Ann 2023; 31:633-643. [PMID: 37264635 DOI: 10.1177/02184923231178704] [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] [Indexed: 06/03/2023]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) has become the preferred treatment for abdominal aortic aneurysm (AAA). Its main aim is to seal the perfusion of the aneurysmal sac and, thus, induce sac regression and subsequent aortic remodelling. Aneurysmal sac regression has been linked to the short- and long-term clinical outcomes post-EVAR. It has also been shown to be influenced by endograft device choice, with several of these available commercially. This review summarises and discusses current evidence on the influence of pre- and intraoperative factors on sac regression. Additionally, this review aims to highlight the device-specific variations in sac regression to provide an overall holistic approach to treating AAAs with EVAR. METHODS A comprehensive literature search was conducted using multiple electronic databases to identify and extract relevant data. RESULTS Female sex, >70 mm original sac diameters, higher pre-procedural fibrinogen levels, smoking and low intra-aneurysmal pressure were found to positively impact sac regression. Whereas renal impairment, ischemic heart disease, high intra-aneurysmal pressure and aneurysm neck thrombus negatively influenced sac regression. Patent lumbar arteries, age, statins and hypercholesterolaemia displayed conflicting evidence regarding sac regression. Regarding the EVAR endografts compared, newer generation devices such as the Anaconda mainly showed the most optimal results. CONCLUSION Sac regression following EVAR in AAA is an important prognostic factor for morbidity and mortality. Nevertheless, several pre- and intraoperative factors can have an influence on sac regression. Therefore, it is necessary to take them into account when assessing AAA patients for EVAR to optimise outcomes. The choice of EVAR stent-graft can also affect sac regression, with evidence suggesting that the Fenestrated Anaconda is associated with the most favourable results.
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Affiliation(s)
- Weronika Nocun
- School of Medicine, University of Nottingham, Nottingham, UK
| | | | | | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Ayah S Alsmadi
- Faculty of Medicine, Jordan University of Science & Technology, Irbid, Jordan
| | | | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales, Cardiff, UK
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Nana P, Spanos K, Kouvelos G, Arnaoutoglou E, Giannoukas A, Matsagkas M. Conical Aortic Neck as a Predictor of Outcome after Endovascular Aneurysm Exclusion: Midterm Results. Ann Vasc Surg 2023; 90:77-84. [PMID: 36460173 DOI: 10.1016/j.avsg.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 11/04/2022] [Accepted: 11/07/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Conical neck may affect endovascular aneurysm repair (EVAR) outcomes. The aim of this study was to present EVAR neck adverse events [endoleak type Ia (ET Ia) and graft migration], in patients with conical neck morphology compared to patients with non-conical necks. An additional analysis of the factors that may affect neck adverse events in patients with conical necks, during the first postoperative year, was executed. METHODS A retrospective analysis of prospective data was conducted, including patients that underwent elective EVAR, between 2017 and 2019. All patients completed the clinical and imaging follow-up of the initial 12 months. Regarding imaging, all cases underwent computed tomography angiography (CTA), preoperatively, at the 1st and 12th month of follow-up. Preoperative and postoperative aneurysm anatomic characteristics (supra-renal and infra-renal aortic diameters, aneurysm diameter, neck angle, thrombus, and calcification) were recorded. Proximal neck was defined as the infrarenal aortic segment, with a diameter less than 30 mm. Conical neck was any neck with a diameter increase ≥2 mm per cm of length (from outer-to-outer aortic wall). The proximal 15 mm of the neck length were considered the zone of endograft sealing. Migration was any ≥10 mm caudal movement of the endograft, relative to its position detected at the CTA of the first month. Neck adverse events were defined as the composite event of ET Ia and migration. RESULTS The cohort included 150 patients; 66 (44%) presented conical neck morphology. No significant difference was detected regarding the preoperative anatomic characteristics between the conical and non-conical groups. Only distal (15 mm) neck diameter was wider in the conical group (P < 0.001). Supra-renal active fixation was used in 63.3% of the total cohort; 59.5% in patients with non-conical necks and 68.2% in patients with conical morphology (P = 0.275). Graft oversizing was 18.2% and 18.7% in the non-conical and conical group, respectively (P = 0.248). Oversizing >20% was equal between groups [37.8% vs. 33.3%% (P = 0.608) while oversizing ≥30% was more common among patients with conical necks (3.5% vs. 10.6%, P < 0.001, 3.2 odds ratio, 95% confidence interval: 0.79, 12.91). Regarding ET Ia and migration, no difference was recorded between the groups. In a subanalysis among patients with conical necks, a lower graft migration rate was detected among patients with higher oversizing rate (P = 0.037). CONCLUSIONS EVAR may offer similarly good midterm outcomes in patients with conical and non-conical neck anatomy. An oversizing to the higher suggested rate may be preventive of graft migration during the first postoperative year in necks with conical morphology. Aggressive oversizing (>20%) do not offer any benefit regarding the prevention of adverse events among patients with conical necks.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Konstantinos Spanos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Eleni Arnaoutoglou
- Anesthesiology Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios Giannoukas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Miltiadis Matsagkas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Bogdanovic M, Siika A, Lindquist Liljeqvist M, Gasser TC, Hultgren R, Roy J. Biomechanics and Early Sac Regression after Endovascular Aneurysm Repair of Abdominal Aortic Aneurysm. JVS Vasc Sci 2023; 4:100104. [PMID: 37152845 PMCID: PMC10160496 DOI: 10.1016/j.jvssci.2023.100104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/01/2023] [Indexed: 04/03/2023] Open
Abstract
Background Sac regression after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) is regarded as a marker of successful response to treatment. Several factors influence sac behavior after EVAR, yet little is known about the value of preoperative biomechanics. The aim of this study was to investigate the difference in aortic biomechanics between patients with and without sac regression. Methods Patients treated with standard EVAR for infrarenal AAA at the Karolinska University Hospital between 2009 and 2012 with one preoperative and a minimum of two postoperative computed tomography angiography (CTA) scans were considered for inclusion in this single-center retrospective cohort study. Biomechanical indices such as AAA wall stress and wall stress-strength ratio as well as intraluminal thrombus (ILT) thickness and stress were measured preoperatively in A4ClinicRE (VASCOPS GmbH). AAA diameter and volume were analyzed on preoperative, 30-day, and 1-year CTAs. Patients were dichotomized based on sac regression, defined as a ≥ 5 mm decrease in maximal AAA diameter between the first two postoperative CTA scans. Multivariable logistic regression was used for analysis of factors associated with early sac regression. Results Of the 101 patients treated during the inclusion period, 64 were included. Thirty-nine (61%) demonstrated sac regression and 25 (39%) had a stable sac or sac increase. The mean patients age (73 years vs 76 years), male sex (85% vs 96%), and median AAA diameter (58 mm vs 58.5 mm) did not differ between patients with and without sac regression. Although no difference in preoperative biomechanics was seen between the groups, multivariable logistic regression revealed that a larger AAA diameter (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.06-1.51; P = .009) and smoking (OR, 22.1; 95% CI, 2.78-174; P = .003) were positively associated with sac regression. In contrast, the lumen diameter (OR, 0.87; 95% CI, 0.77-0.98; P = .023), ILT thickness (OR, 0.85; 95% CI, 0.75-0.97; P = .013), aspirin or direct-acting oral anticoagulant use (OR, 0.11; 95% CI, 0.02-0.61; P = .012), and mean ILT stress (OR, 0.35; 95% CI, 0.14-0.87; P = .024) showed a negative association. Patients with sac regression had fewer reinterventions (log-rank P = .010) and lower mortality (log-rank P = .012) at the 5-year follow-up. Conclusions This study, characterizing preoperative biomechanics in patients with and without sac regression, demonstrated a negative association between mean ILT stress and ILT thickness with a change in sac diameter after EVAR. Given that the ILT is a highly dynamic entity, further studies focusing on the role of the thrombus are needed. Furthermore, patients presenting with early sac regression had improved outcomes after EVAR.
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Fiotti N, Girolamo FD, Lepidi S, Biolo G, D'Oria M. Reply to: "Analysis of the association of clinical, surgical and genetic factors with aneurysm sac remodeling after endovascular repair" by Martins et al. Cardiovasc Pathol 2022; 61:107455. [PMID: 35870787 DOI: 10.1016/j.carpath.2022.107455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 11/03/2022] Open
Affiliation(s)
- N Fiotti
- Unit of Clinica Medica, Department of Medical, Surgical and Health Sciences of the University of Trieste, Strada di Fiume, 447 Cattinara, 34149 Trieste, Italy.
| | - Fg di Girolamo
- Unit of Clinica Medica, Department of Medical, Surgical and Health Sciences of the University of Trieste, Strada di Fiume, 447 Cattinara, 34149 Trieste, Italy
| | - S Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Strada di Fiume, 447 Cattinara, 34149, Trieste, Italy
| | - G Biolo
- Unit of Clinica Medica, Department of Medical, Surgical and Health Sciences of the University of Trieste, Strada di Fiume, 447 Cattinara, 34149 Trieste, Italy
| | - M D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Strada di Fiume, 447 Cattinara, 34149, Trieste, Italy
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Analysis of the association of clinical, surgical and genetic factors with aneurysm sac remodeling after endovascular repair. Cardiovasc Pathol 2022; 61:107454. [PMID: 35858668 DOI: 10.1016/j.carpath.2022.107454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/21/2022] [Accepted: 07/13/2022] [Indexed: 11/21/2022] Open
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Stern JR, Lee JT. Factors Associated with Sac Regression after F/BEVAR for Complex Abdominal and Thoracoabdominal Aneurysms. Semin Vasc Surg 2022; 35:306-311. [DOI: 10.1053/j.semvascsurg.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/09/2022] [Accepted: 07/20/2022] [Indexed: 11/11/2022]
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Esposito D, Fargion AT, Dorigo W, Melani A, Capone A, DI Domenico R, Villani F, Speziali S, Pratesi C. Stability of the aneurysmatic sac post-EVAR could no longer be a reliable criterion of healing. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:155-159. [PMID: 34825794 DOI: 10.23736/s0021-9509.21.12014-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Evaluation of the impact of aneurysm sac behavior in terms of either stability or shrinkage after endovascular aneurysm repair (EVAR) on long-term clinical outcomes. METHODS A retrospective study was conducted on 1483 consecutive patients who underwent EVAR from 1999 to 2021 at our institution. 1037 patients met inclusion criteria (1037/1483, 69.9%): abdominal aortic or aorto-iliac aneurysm, elective surgery, follow-up (FU) ≥12 months. Patients who had sac stability (330/1037, 31.8%) and patients who demonstrated sac shrinkage (542/1037, 52.2%) at FU were compared; patients who presented sac increase at FU were excluded (165/1037, 16%). PRIMARY ENDPOINTS rupture rates, need for surgical conversion, and long-term aneurysm-related mortality. Secondary endpoints: all type endoleak rates and long-term reintervention rates. RESULTS Mean FU was 61.2 months (IQ 26-85.7 months). In terms of comorbidities, the group of patients with stable sac showed greater association with polidistrectual atherosclerotic manifestations. Estimated 12-year survival was 42.9% in the stable sac group and 65% in the shrinked group (P<0.001), although there were no significant differences in terms of freedom from aneurysm-related death (97.3% vs. 95.4% estimated at 12 years, P=0.493). Patients with sac stability had higher rates of rupture (2.1% vs. 0.6%, P=0.035) and surgical conversion (2.1% vs. 0.6%, P=0.035). The stable sac group had significantly higher rates of all type endoleak during FU (45.8% vs. 24%, P<0.001). Estimated 12-year freedom from reintervention rates were 56.2% and 83.9% respectively (P<0.001). CONCLUSIONS After more than 20 years of EVAR experience it is probably time to reconsider the procedure clinical success parameters as a patient with a stable sac cannot be considered healed.
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Affiliation(s)
- Davide Esposito
- Department of Excellence in Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy -
| | - Aaron T Fargion
- Department of Excellence in Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Walter Dorigo
- Department of Excellence in Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Alberto Melani
- Department of Excellence in Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Amedeo Capone
- Department of Excellence in Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Rossella DI Domenico
- Department of Excellence in Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Flavio Villani
- Department of Excellence in Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Sara Speziali
- Department of Excellence in Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Carlo Pratesi
- Department of Excellence in Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
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van Rijswijk RE, Groot Jebbink E, Holewijn S, Stoop N, van Sterkenburg SM, Reijnen MMPJ. Predictors of Abdominal Aortic Aneurysm Shrinkage after Endovascular Repair. J Clin Med 2022; 11:jcm11051394. [PMID: 35268486 PMCID: PMC8910935 DOI: 10.3390/jcm11051394] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 02/01/2023] Open
Abstract
Recent studies demonstrate that patients with a shrinking abdominal aortic aneurysm (AAA), one-year after endovascular repair (EVAR), have better long-term outcomes than patients with a stable AAA. It is not known what factors determine whether an AAA will shrink or not. In this study, a range of parameters was investigated to identify their use in differentiating patients that will develop a shrinking AAA from those with a stable AAA one-year after EVAR. Hundred-seventy-four patients (67 shrinking AAA, 107 stable AAA) who underwent elective, infrarenal EVAR were enrolled between 2011-2018. Long-term survival was significantly better in patients with a shrinking AAA, compared to those with a stable AAA (p = 0.038). Larger preoperative maximum AAA diameter was associated with an increased likelihood of developing AAA shrinkage one-year after EVAR-whereas older age and larger preoperative infrarenal β angle were associated with a reduced likelihood of AAA shrinkage. However, this multivariate logistic regression model was only able to correctly identify 66.7% of patients with AAA shrinkage from the total cohort. This is not sufficient for implementation in clinical care, and therefore future research is recommended to dive deeper into AAA anatomy, and explore potential predictors using artificial intelligence and radiomics.
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Affiliation(s)
- Rianne E. van Rijswijk
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, 7522 NH Enschede, The Netherlands
- Correspondence:
| | - Erik Groot Jebbink
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, 7522 NH Enschede, The Netherlands
| | - Suzanne Holewijn
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
| | - Nicky Stoop
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
| | - Steven M. van Sterkenburg
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
| | - Michel M. P. J. Reijnen
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, 7522 NH Enschede, The Netherlands
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Boer GJ, Schröder LBW, Disli MC, Kuijper TM, van de Luijtgaarden KM, Fioole B. A stable aneurysm sac after endovascular aneurysm repair as a predictor for mortality, an in-depth analysis. J Vasc Surg 2022; 76:445-453. [PMID: 35149164 DOI: 10.1016/j.jvs.2022.01.125] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/21/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to compare the long-term survival in patients with a stable aneurysmal sac and those with aneurysmal sac regression after endovascular aneurysm repair (EVAR) and to identify independent risk factors for aneurysmal sac regression and mortality after EVAR. METHODS We reviewed all patients who underwent EVAR between 2005 and 2018 with a computed tomography angiography available at 1-year follow-up. Aneurysm sac regression was defined as a diameter decrease of more than 10%. We used a multivariable regression to identify independent risk factors for sac regression. Kaplan-Meier analysis and Cox regression were done to test differences in 5-year mortality between a stable sac and sac regression. RESULTS The inclusion criteria were met by 325 patients, 185 in the sac regression group and 140 in the stable sac group. Multivariable logistic regression analysis showed that treatment for a ruptured aneurysm was an independent risk factor for aneurysmal sac regression (hazard ratio [HR], 0.26; 95% confidence interval [CI], 0.07-0.96). Age (HR, 1.05; 95% CI, 1.01-1.09), ischemic heart disease (HR, 1.94; 95% CI, 1.13-3.31), neck thrombus (HR, 2.72; 95% CI, 1.07-6.95), and a type II endoleak (HR, 19.21; 95% CI, 7.32-50.40) were independent risk factors for a stable aneurysm sac diameter. Multivariable Cox regression showed a significantly increased risk of mortality for patients with a stable aneurysm sac after EVAR (odds ratio, 2.25; 95% CI, 1.36-3.72). There was no significant difference in cause of death between the two groups. CONCLUSION A stable aneurysm sac after EVAR is associated with increased mortality. Age, ischemic heart disease, neck thrombus, and a type II endoleak are independent risk factors for a stable sac. However, a well-founded explanation for this finding is still lacking. Future research should be focussed on aggressive treatment of type II endoleaks and inflammatory processes as potential pathophysiological mechanisms.
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Affiliation(s)
- Gert Jan Boer
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands.
| | | | - Maksud C Disli
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Tjallingius M Kuijper
- Clinical epidemiologist and statistician, Maasstad Academy, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
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D'Oria M, Di Girolamo FG, Calvagna C, Gorgatti F, Altamura N, Lepidi S, Biolo G, Fiotti N. Remodeling of abdominal Aortic Aneurysm Sac following EndoVascular Aortic Repair: Association with Clinical, Surgical, and Genetic factors. Cardiovasc Pathol 2021; 58:107405. [PMID: 34968687 DOI: 10.1016/j.carpath.2021.107405] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 11/15/2022] Open
Abstract
After successful EndoVascular Aortic Repair (EVAR), abdominal aortic aneurysms (AAA) sac will undergo negative remodeling (i.e. shrinkage) as a measure of successful exclusion. Determinants of shrinkage after EVAR are not fully known. In 84 post-EVAR patients, time course of AAA diameter after repair and occurrence of endoleaks (ELs) have been correlated with clinical history, medications, anthropometric data, vascular anatomy, and matrix metalloprotease (MMP) genetic variants (namely MMP-1 rs1799750, MMP-3 rs35068180, MMP-9 rs2234681, rs917576, rs917577, MMP-12 rs652438, and TIMP1 rs4898). During follow-up, 41 ELs were detected in 37 patients (44%, 10.4 events/100 pt./y), accounting for AAA dilation or reduced shrinkage (P<0.001). High-flow ELs (type 1 and/or 3) occurrence was associated with warfarin use, MMP9 rs17577 polymorphism, and unfavorable anatomy, while low-flow type 2 ELs occurred more often in TIMP1 rs4898 non-T carriers. In EL-free patients, AAA diameter decreased for the first three years, (-4, -3 and - 2 mm/year respectively) and remained stable thereafter. Shrinkage between two measurements (n= 120) was associated with smaller AAA diameter at the baseline, peripheral arterial disease (PAD), patients' older age at intervention, and G-/G- genotype in MMP1 rs1799750 (binary logistic regression, P=0.0001). Aneurysmal sac shrinking occurs for few years after EVAR, only in patients without EL, and is related to older age, PAD, smaller aneurysm size and putative lower MMP1 expression while EL occurrence prevents such a remodeling and is mainly related to local-acting factors like unfavorable anatomy, anticoagulation, and MMP9 and TIMP1 genetic polymorphisms.
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Affiliation(s)
- Mario D'Oria
- Unit of Chirurgia Vascolare, Strada di Fiume, 447 34149 Cattinara TRIESTE, ITALY
| | - Filippo Giorgio Di Girolamo
- Unit of Clinica Medica. Department of Medical, Surgical and Health Sciences of the University of Trieste, Strada di Fiume, 447 34149 Cattinara TRIESTE, ITALY
| | - Cristiano Calvagna
- Unit of Chirurgia Vascolare, Strada di Fiume, 447 34149 Cattinara TRIESTE, ITALY
| | - Filippo Gorgatti
- Unit of Chirurgia Vascolare, Strada di Fiume, 447 34149 Cattinara TRIESTE, ITALY
| | - Nicola Altamura
- Unit of Clinica Medica. Department of Medical, Surgical and Health Sciences of the University of Trieste, Strada di Fiume, 447 34149 Cattinara TRIESTE, ITALY
| | - Sandro Lepidi
- Unit of Chirurgia Vascolare, Strada di Fiume, 447 34149 Cattinara TRIESTE, ITALY
| | - Gianni Biolo
- Unit of Clinica Medica. Department of Medical, Surgical and Health Sciences of the University of Trieste, Strada di Fiume, 447 34149 Cattinara TRIESTE, ITALY
| | - Nicola Fiotti
- Unit of Clinica Medica. Department of Medical, Surgical and Health Sciences of the University of Trieste, Strada di Fiume, 447 34149 Cattinara TRIESTE, ITALY.
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Morisaki K, Matsubara Y, Furuyama T, Kurose S, Yoshino S, Yamashita S, Mori M. Effects of antithrombotic therapy on abdominal aortic aneurysm sac size after endovascular repair in patients with favorable neck anatomy. J Vasc Interv Radiol 2021; 33:113-119. [PMID: 34742897 DOI: 10.1016/j.jvir.2021.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/16/2021] [Accepted: 10/26/2021] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To evaluate the influence of antiplatelet or anticoagulant therapy on sac behavior after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) MATERIALS AND METHODS: This study retrospectively analyzed data from patients with favorable neck anatomy who underwent EVAR between 2007 and 2019. Patients with ruptured AAA and ≤1 year of sac behavior evaluation were excluded. Sac shrinkage after 1 year, persistent type II endoleak, and late sac expansion were examined. RESULTS In total, 182 patients with favorable neck anatomy were included in this study. Multivariable analysis identified occluded inferior mesenteric artery (IMA [P = .049]), presence of posterior thrombus (P = .009) and no antiplatelet therapy (P = .012) as factors positively associated with sac shrinkage at 1 year. Persistent type II endoleak was detected in 56 (30.8%) patients, with patent IMA (P = .006), lack of posterior thrombus (P = .004), number of patent lumbar arteries (P = .004), and antiplatelet therapy (P = .039) being identified as significant risk factors. Multivariable analysis identified larger initial AAA diameter (P < .001), lack of posterior thrombus (P = .038), and antiplatelet (P = .038) and anticoagulation therapies (P = .003) as risk factors for late sac expansion. CONCLUSIONS After EVAR in patients with favorable neck anatomy, antiplatelet therapy is associated with lack of sac regression at 1 year, whereas antiplatelet and anticoagulant therapies are risk factors for late sac expansion.
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Affiliation(s)
- Koichi Morisaki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Yutaka Matsubara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Tadashi Furuyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Shun Kurose
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Shinichiro Yoshino
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Sho Yamashita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Masaki Mori
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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