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Paajanen P, Karjalainen J, Jaroma M, Tarkiainen M, Manninen H, Mäkinen K, Kärkkäinen J, Saari P. Friendly Neck Anatomy Does Not Prevent Neck-Related Adverse Events After EVAR. Ann Vasc Surg 2024; 104:71-80. [PMID: 37454900 DOI: 10.1016/j.avsg.2023.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/12/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Life-long follow-up after endovascular aneurysm repair (EVAR) is costly and burdensome to the patient. Follow-up should be stratified based on the risk of EVAR failure. Aneurysm neck is thought to be the single most important risk factor. This study investigated neck anatomy as a predictor of neck-related adverse events after EVAR. METHODS This retrospective single-center study included consecutive patients undergoing elective EVAR for infrarenal abdominal aortic aneurysms between 2011 and 2016 (n = 222) who were followed with yearly imaging until December 2020. Hostile neck was defined as neck length ≤15 mm, width ≥28 mm, angulation ≥60°, calcification, or thrombus ≥50% of circumference or conical neck based on preoperative computed tomography angiography. Neck-related adverse event was defined as aneurysm rupture, any neck-related reintervention or type 1a endoleak during follow-up. RESULTS Ninety (41%) patients had hostile neck and 132 (59%) had friendly neck. There were no differences in 30-day mortality (1% vs. 1%, P = 0.78), major adverse events (20% vs. 16%, P = 0.43) or reinterventions during the hospital stay (8% vs. 4%, P = 0.20) between patients with hostile and friendly neck. Estimated survival at 1 year was 89 ± 3% for hostile neck and 95 ± 2% for friendly neck patients (P < 0.01). Five-year survival estimates were 51 ± 6% and 66 ± 4%, respectively. Aneurysm-related mortality was higher after 6 years in patients with hostile neck (P < 0.01). Twenty-four patients (11%) suffered neck-related adverse events with mean time-to-event of 3.3 ± 2.8 years; there were no differences between the groups stratified by neck anatomy. Incidentally, preoperative aneurysm diameter was found to be an independent risk factor for neck-related adverse events and aneurysm-related mortality; 53 patients (24%) had aneurysm diameter ≥70 mm, which was associated with nearly 4-fold risk of neck-related complications during the follow-up. CONCLUSIONS Friendly neck anatomy may not protect from neck-related adverse events after EVAR in the long-term. Especially patients with large aneurysms should be followed closely.
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Affiliation(s)
- Paavo Paajanen
- Heart Center, Kuopio University Hospital, Kuopio, Finland; University of Eastern Finland, Kuopio, Finland.
| | | | | | - Mika Tarkiainen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Hannu Manninen
- University of Eastern Finland, Kuopio, Finland; Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Kimmo Mäkinen
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | | | - Petri Saari
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
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Gonring DW, Zottola ZR, Hirad AA, Lakony R, Richards MS, Pitcher G, Stoner MC, Mix DS. Ultrasound elastography to quantify average percent pressure-normalized strain reduction associated with different aortic endografts in 3D-printed hydrogel phantoms. JVS Vasc Sci 2024; 5:100198. [PMID: 38846626 PMCID: PMC11153908 DOI: 10.1016/j.jvssci.2024.100198] [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: 09/11/2023] [Accepted: 02/23/2024] [Indexed: 06/09/2024] Open
Abstract
Objective Strain has become a viable index for evaluating abdominal aortic aneurysm stability after endovascular aneurysm repair (EVAR). In addition, literature has shown that healthy aortic tissue requires a degree of strain to maintain homeostasis. This has led to the hypothesis that too much strain reduction conferred by a high degree of graft oversizing is detrimental to the aneurysm neck in the seal zone of abdominal aortic aneurysms after EVAR. We investigated this in a laboratory experiment by examining the effects that graft oversizing has on the pressure-normalized strain (ε ρ + ¯ /pulse pressure [PP]) reduction using four different infrarenal EVAR endografts and our ultrasound elastography technique. Approximate graft oversizing percentages were 20% (30 mm phantom-graft combinations), 30% (28 mm phantom-graft combinations), and 50% (24 mm phantom-graft combinations). Methods Axisymmetric, 10% by mass polyvinyl alcohol phantoms were connected to a flow simulator. Ultrasound elastography was performed before and after implantation with the four different endografts: (1) 36 mm polyester/stainless steel, (2) 36 mm polyester/electropolished nitinol, (3) 35 mm polytetrafluoroethylene (PTFE)/nitinol, and (4) 36 mm nitinol/polyester/platinum-iridium. Five ultrasound cine loops were taken of each phantom-graft combination. They were analyzed over two different cardiac cycles (end-diastole to end-diastole), yielding a total of 10 maximum mean principal strain (ε ρ + ¯ ) values.ε ρ + ¯ was divided by pulse pressure to yield pressure-normalized strain (ε ρ + ¯ /PP). An analysis of variance was performed for graft comparisons. We calculated the average percentε ρ + ¯ /PP reduction by manufacturer and percent oversizing. These values were used for linear regression analysis. Results Results from one-way analysis of variance showed a significant difference inε ρ + ¯ /PP between the empty phantom condition and all oversizing conditions for all graft manufacturers (F(3, 56) = 106.7 [graft A], 132.7 [graft B], 106.5 [graft C], 105.7 [graft D], P < .0001 for grafts A-D). There was a significant difference when comparing the 50% condition with the 30% and 20% conditions across all manufacturers by post hoc analysis (P < .0001). No significant difference was found when comparing the 20% and 30% oversizing conditions for any of the manufacturers or when comparingε ρ + ¯ /PP values across the manufacturers according to percent oversize. Linear regression demonstrated a significant positive correlation between the percent graft oversize and the all-graft average percentε ρ + ¯ /PP reduction (R 2 = 0.84, P < .0001). Conclusions This brief report suggests that a 10% increase in graft oversizing leads to an approximate 5.9% reduction inε ρ + ¯ /PP on average. Applied clinically, this increase may result in increased stiffness in axisymmetric vessels after EVAR. Further research is needed to determine if this is clinically significant.
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Affiliation(s)
- Dakota W. Gonring
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | | | - Adnan A. Hirad
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Ronald Lakony
- Hajim School of Engineering and Applied Sciences, University of Rochester, Rochester, NY
| | - Michael S. Richards
- Department of Biomedical Engineering, Rochester Institute of Technology, Rochester, NY
| | - Grayson Pitcher
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Michael C. Stoner
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Doran S. Mix
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
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Jan Boer G, Bekken JA, Kuijper TM, Vroegindeweij D, Fioole B. The Ratio Between the Infrarenal and Suprarenal Aortic Diameter Is a Predictor of Durable Proximal Seal After Endovascular Aneurysm Repair. J Endovasc Ther 2024:15266028241228803. [PMID: 38323563 DOI: 10.1177/15266028241228803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
OBJECTIVES The aim of this study was to assess whether the ratio of the mean infrarenal neck diameter to the suprarenal aortic diameter is a predictor for a durable proximal seal after endovascular aneurysm repair (EVAR). METHODS A total of 439 patients who underwent elective EVAR between 2004 and 2018 in a single vascular referral center met our inclusion criteria. Ratios were calculated by dividing the mean infrarenal neck diameter by 4 different suprarenal aortic diameters. Patients who developed a late type 1A endoleak (n=20) or proximal neck dilatation mandating revision (n=8) were compared with the 411 patients without long-term proximal seal complications. RESULTS Patients who developed a late type 1A endoleak had more frequently hypertension, a shorter infrarenal neck length, and a larger mean infrarenal neck diameter. The ratio of the mean infrarenal neck diameter to all 4 suprarenal aortic diameters was higher in the late type 1A endoleak group compared with the group without a late type 1A endoleak. Least absolute shrinkage and selection operator (LASSO) logistic regression identified a combination of 6 variables as the best combination to predict a late type 1A endoleak: presence of hypertension, increased mean infrarenal neck diameter, decreased aneurysm neck length, larger ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the superior mesenteric artery (SMA), larger ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the upper renal artery, and increased β-angle. Of these, based on both the univariate area under the curve (AUC) and optimal LASSO model restricted to a single predictor, the ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the SMA (AUC, 0.770; cutoff value, 0.997) was considered the best prognostic variable. CONCLUSION The ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the SMA is a good predictor for a late type 1A endoleak. Patients with mean infrarenal neck diameter larger than the diameter proximal to the SMA (ratio >1) are at risk for a late type 1A endoleak. CLINICAL IMPACT In this single-center, retrospective cohort study, we found that the ratio of the mean infrarenal neck diameter to the aortic diameter proximal to the SMA is a good predictor for a late type 1A endoleak. We conclude that the suprarenal diameter must be taken into account before assessing endovascular aortic aneurysm repair eligibility. Patients with a ratio >1 may not be the best candidates for a durable result after EVAR and may be better off with fenestrated EVAR or open repair.
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Affiliation(s)
- Gert Jan Boer
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Joost A Bekken
- Department of Vascular Surgery, NoordWest Hospitalgroup, Haarlem, The Netherlands
| | | | | | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, The Netherlands
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Özdemir-van Brunschot DMD, Tevs M, Holzhey D. Results of the Chimney Technique in a Community Hospital. Vasc Endovascular Surg 2024; 58:20-28. [PMID: 37349149 DOI: 10.1177/15385744231185640] [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: 06/24/2023]
Abstract
BACKGROUND The chimney technique, fenestrated or branched endovascular aortic repair are endovascular options in patients with a juxtarenal, suprarenal or type IV thoraco-abdominal aneurysm. The chimney technique has specific advantages and disadvantages. A retrospective single center study was performed to describe the results. PATIENTS AND METHODS All consecutive patients in whom the chimney technique was used between 1th January 2011 and 31th December 2020 were included. We excluded patients who needed a revision of an existing EVAR and patients with a para-anastomotic aneurysm. Outcomes were reported in accordance with the reporting standards. RESULTS 38 Patients were included in the study, a total of 59 chimney grafts were deployed. At a median follow-up duration of 26.6 months, there were 9 patients with occlusion of the chimney graft. In 1 patient an iliac renal bypass was performed. In the other patients the renal function stabilized and no further therapy was necessary. All chimneys in the mesenteric arteries remained patent. Gutter endoleak was seen in 5 patients, 3 patients were successfully treated and in the other 2 patients the gutter endoleak disappeared spontaneously. CONCLUSIONS Conclusions should be drawn carefully as this is a retrospective non-comparative study. Results from 38 patients treated with the chimney technique are presented. Chimney graft occlusion rate was 15.3% at the end of follow-up. However, the majority (77.8%) of the occluded stents were self-expandable stents, stressing the importance of selecting the right devices.
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Affiliation(s)
- Denise M D Özdemir-van Brunschot
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group Düsseldorf, Düsseldorf, Germany
- Faculty of Health, University Witten/Herdecke, Witten, Germany
| | - Maria Tevs
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group Düsseldorf, Düsseldorf, Germany
| | - David Holzhey
- Faculty of Health, University Witten/Herdecke, Witten, Germany
- Department of Cardiac Surgery, Helios University Hospital Wuppertal, Wuppertal, Germany
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Cifuentes S, Mendes BC, Tabiei A, Scali ST, Oderich GS, DeMartino RR. Management of Endoleaks After Elective Infrarenal Aortic Endovascular Aneurysm Repair: A Review. JAMA Surg 2023; 158:965-973. [PMID: 37494030 DOI: 10.1001/jamasurg.2023.2934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Importance Endovascular aneurysm repair (EVAR) is the dominant treatment strategy for abdominal aortic aneurysms, encompassing 80% of all repairs in the United States. Endoleaks are ubiquitous and affect 30% of patients treated by EVAR, potentially leading to sac enlargement and increased risk of rupture. The care of EVAR patients requires long-term surveillance by a multidisciplinary team. Accordingly, physicians should be familiar with the fundamentals of endoleak management to achieve optimal outcomes, including timely referral for remediation or providing counseling and reassurance when needed. Observations PubMed and the Cochrane database were searched for articles published between January 2002 and December 2022 in English, addressing epidemiology, diagnosis, and management of endoleaks after EVAR. Endoleaks can be detected intraoperatively or years later, making lifelong surveillance mandatory. Type I and III have the highest risk of rupture (7.5% at 2 years and 8.9% at 1 year, respectively) and should be treated when identified. Intervention should be considered for other types of endoleak when associated with aneurysm sac growth larger than 5 mm based on current guidelines. Type II endoleaks are the most common, accounting for 50% of all endoleaks. Up to 90% of type II endoleaks resolve spontaneously or are not associated with sac enlargement, requiring only observation. Although the risk of rupture is less than 1%, cases that require reintervention are challenging. Recurrence is common despite endovascular treatment, and rupture can occur without evidence of sac growth. Type IV endoleaks and endotension are uncommon, are typically benign, and primarily should be observed. Conclusions and Relevance Endoleak management depends on the type and presence of sac expansion. Type I and III endoleaks require intervention. Type II endoleaks should be observed and treated selectively in patients with significant sac expansion. Since endoleaks can appear any time after EVAR, at least 1 contrast-enhanced computed tomographic angiogram or duplex ultrasound by an experienced laboratory is recommended every 5 years.
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Affiliation(s)
- Sebastian Cifuentes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Armin Tabiei
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Randall R DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota
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Zuidema R, Geraedts ACM, van Veldhuizen WA, Mulay S, de Vries JPPM, Schuurmann RCL, Balm R. Diminishing Endograft Apposition during Follow-Up Is an Important Indicator of Late Type 1a Endoleak after Endovascular Aneurysm Repair. J Clin Med 2023; 12:3969. [PMID: 37373662 PMCID: PMC10299238 DOI: 10.3390/jcm12123969] [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: 04/26/2023] [Revised: 05/30/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Late type 1a endoleaks (T1aELs) after endovascular aneurysm repair (EVAR) are hazardous complications which should be avoided. This study investigated the evolution of the shortest apposition length (SAL) post-EVAR and hypothesised that a declining apposition during follow-up may be an indicator of T1aEL development. Patients with a late T1aEL were selected from a consecutive multicentre database. For each T1aEL patient, the preoperative computed tomography angiography (CTA), first postoperative CTA, and pre-endoleak CTA were analysed. T1aEL patients were matched 1:1 to uncomplicated controls, based on endograft type and follow-up duration. Anatomical characteristics and endograft dimensions, including the post-EVAR SAL, were measured. Included were 28 patients with a late T1aEL and 28 matched controls. The SAL decreased from 11.2 mm (5.6-20.6 mm) to 3.9 mm (0.0-11.4 mm) in the T1aEL group (p = 0.006), whereas an increase in SAL was seen in the control group from 21.3 mm (14.1-25.8 mm) to 25.4 mm (19.0-36.2 mm; p = 0.015). On the pre-endoleak CTA, 18 patients (64%) in the T1aEL group had a SAL < 10 mm, and one (4%) patient in the control group had a SAL < 10 mm on the matched CTAs. Moreover, three mechanisms of decreasing sealing zone were identified, which might be used to determine optimal imaging or reintervention strategies. Diminishing SAL < 10 mm is an indicator for T1aEL during follow-up, it is imperative to include apposition analysis during follow-up.
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Affiliation(s)
- Roy Zuidema
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (W.A.v.V.); (J.-P.P.M.d.V.); (R.C.L.S.)
| | - Anna C. M. Geraedts
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (A.C.M.G.); (S.M.); (R.B.)
| | - Willemina A. van Veldhuizen
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (W.A.v.V.); (J.-P.P.M.d.V.); (R.C.L.S.)
| | - Sana Mulay
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (A.C.M.G.); (S.M.); (R.B.)
| | - Jean-Paul P. M. de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (W.A.v.V.); (J.-P.P.M.d.V.); (R.C.L.S.)
| | - Richte C. L. Schuurmann
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (W.A.v.V.); (J.-P.P.M.d.V.); (R.C.L.S.)
| | - Ron Balm
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (A.C.M.G.); (S.M.); (R.B.)
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Özdemir-van Brunschot D, Harrich F, Tevs M, Holzhey D. Risk factors of type 1A endoleak following endovascular aortic aneurysm repair. Vascular 2023:17085381231162393. [PMID: 36893459 DOI: 10.1177/17085381231162393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
OBJECTIVES Endovascular repair of infrarenal aortic aneurysms are the treatment of first choice. However, the proximal sealing of endovascular aneurysm repair is the Achilles' heel of the procedure. Insufficient proximal sealing can lead to endoleak type 1A and therefore expansion of the aneurysm sack and subsequent rupture. METHODS We performed a retrospective analysis of all consecutive patients with an infrarenal abdominal aneurysm treated with endovascular aneurysm repair. We studied whether demographic and anatomical features were risk factors for endoleak type 1A. Also, the results of different treatment strategies were described. RESULTS 257 Patients were included in the study, most patients were male. In the multivariate analysis, female gender and infrarenal angulation were the most important risk factors for endoleak type 1A. Endoleak type 1A diagnosed at completion angiography disappeared in 77.8%. The occurrence of endoleak type 1A was associated with a higher risk of aneurysm-related mortality (p = 0.01). CONCLUSION Conclusions should be drawn with care, since the number of patients included in this study was small and there was a high incidence of patients lost to follow-up. This study suggests that endovascular aneurysm repair in female patients and patients with severe infrarenal angulation is associated with a higher risk of endoleak type 1A.
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Affiliation(s)
- Dmd Özdemir-van Brunschot
- German Faculty of Health, 39568Witten/Herdecke University, Witten, Germany.,Department of Vascular Surgery and Endovascular Therapy, 39568Augusta Hospital and Catholic Hospital Group, Düsseldorf, Germany
| | - Fhm Harrich
- Department of Geneal, Visceral, Thoracic and Endocrine Surgery, 39568Augusta Hospital and Catholic Hospital Group, Düsseldorf, Germany
| | - M Tevs
- Department of Vascular Surgery and Endovascular Therapy, 39568Augusta Hospital and Catholic Hospital Group, Düsseldorf, Germany
| | - D Holzhey
- German Faculty of Health, 39568Witten/Herdecke University, Witten, Germany.,Department of Cardiac Surgery, 60865Helios Universitätsklinikum Wuppertal, Wuppertal, Germany
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