Aneurysm Rupture after EVAR: Can the Ultimate Failure be Predicted?

Implantable Pressure-Sensing Devices for Monitoring Abdominal Aortic Aneurysms in Post-Endovascular Aneurysm Repair

Over the past two decades, there has been extensive research into surveillance methods for the post-endovascular repair of abdominal aortic aneurysms, highlighting the importance of these technologies in supplementing or even replacing conventional image-screening modalities. This review aims to provide an overview of the current status of alternative surveillance solutions for endovascular aneurysm repair, while also identifying potential aneurysm features that could be used to develop novel monitoring technologies. It offers a comprehensive review of these recent clinical advances, comparing new and standard clinical practices. After introducing the clinical understanding of abdominal aortic aneurysms and exploring current treatment procedures, the paper discusses the current surveillance methods for endovascular repair, contrasting them with recent pressure-sensing technologies. The literature on three commercial pressure-sensing devices for post-endovascular repair surveillance is analyzed. Various pre-clinical and clinical studies assessing the safety and efficacy of these devices are reviewed, providing a comparative summary of their outcomes. The review of the results from pre-clinical and clinical studies suggests a consistent trend of decreased blood pressure in the excluded aneurysm sac post-repair. However, despite successful pressure readings from the aneurysm sac, no strong link has been established to translate these measurements into the presence or absence of endoleaks. Furthermore, the results do not allow for a conclusive determination of ongoing aneurysm sac growth. Consequently, a strong clinical need persists for monitoring endoleaks and aneurysm growth following endovascular repair.

Injection of n-Butyl-2-Cyanoacrylate into the Abdominal Aortic Aneurysm Sac during Endovascular Aortic Repair to Prevent Type II Endoleaks Caused by Lumbar Arteries

PURPOSE

To evaluate midterm results of whether the strategy to occlude target lumbar arteries using n-butyl-2-cyanoacrylate (nBCA) injection during endovascular aneurysm repair (EVAR) reduced the incidence of Type II endoleak (T2EL) after EVAR.

MATERIALS AND METHODS

Between 2013 and 2020, 187 patients underwent EVAR; 106 in the treatment group received nBCA injection during EVAR, whereas 81 in the historical control group did not. The incidence of T2EL at 7 days, need for reintervention, and post-EVAR aneurysmal shrinkage were compared between the groups.

RESULTS

Between the treatment group and the control group, significant differences were achieved in the incidence of T2EL (2.8% vs 28.4%; P < .0001) and decreased aneurysmal diameter was observed at 1 year after EVAR (-5.2 vs -3.8 mm; P = .034). In multivariate analysis, nBCA injection (odds ratio [OR], 0.04; P = .001) and younger age (OR, 0.92; P = .036) were significantly associated with a reduced incidence of T2EL. As a possible adverse event associated with nBCA injection, 2 cases of transient lower-limb motor dysfunction (1.9%) were observed. Propensity score analysis revealed that the treatment group had a significantly lower incidence of T2EL than that in the control group (P = .0002) even though there was no difference in the incidence of inferior mesenteric artery coil embolization between the groups. The survival rate without aneurysm sac enlargement (100.0% vs 69.8%; P = .014) and the reintervention-free rate (100.0% vs 63.1%; P = .034) in the treatment group were significantly higher than those in the control group.

CONCLUSIONS

Concomitant nBCA injection can provide durable EVAR without T2EL, as supported by the avoidance of reintervention associated with aneurysm sac enlargement.

Individualizing Surveillance after Endovascular Aortic Repair Using a Modular Imaging Algorithm

OBJECTIVES

Surveillance after endovascular aortic repair (EVAR) and fenestrated EVAR (FEVAR) is mainly directed by one-size-fits-all approaches instead of personalized decision making, even though treatment strategies and often endografts themselves are tailor-made to adjust for individual patients. We propose a modular imaging algorithm that escalates surveillance imaging based on invasiveness and need.

MATERIALS AND METHODS

In this retrospective observational study of single-center data, results of a modular imaging algorithm were analyzed. The algorithm is characterized by initiating the examination with standard B-mode then transitioning to Duplex ultrasound, B-Flow, and CEUS. Additional CT(A) studies are conducted where required. The study population included both patients receiving EVAR or FEVAR. A comparative analysis was conducted regarding endoleak detection.

RESULTS

The study population included 28 patients receiving EVAR and 40 patients receiving FEVAR. They accounted for 101 follow-up visits, which led to 431 distinct imaging studies. CEUS has the highest endoleak detection rate, followed by CTA and B-Flow. Duplex ultrasound and B-Flow resulted in 0 and 1 false positive cases, respectively, considering CEUS the reference standard. In a select group of six patients, CEUS was omitted after endoleaks were displayed by Duplex ultrasound or B-Flow, leading to a successful type II coiling and no aneurysm-related adverse events.

CONCLUSIONS

The proposed modular algorithm showed great potential to incorporate principles of personalized medicine in surveillance after endovascular aortic treatment. Since Duplex ultrasound and B-Flow rarely cause false positive endoleaks, more resource-intensive and invasive imaging studies such as CEUS and CTA can be omitted after positive identification.

Implications and late outcomes of type II endoleaks after endovascular aneurysm repair

OBJECTIVE

Type II endoleaks (T2ELs) are the most common cause of reintervention after endovascular aneurysm repair (EVAR). Although most resolve spontaneously, the long-term implications of T2ELs remain elusive. We aim to evaluate the impact of persistent and late T2ELs on clinical outcomes after EVAR.

METHODS

This was a single-institution retrospective review of patients who underwent EVAR for degenerative infrarenal abdominal aortic aneurysm between January 2010 and June 2022 with no type I (T1EL) or III (T3EL) endoleak seen at EVAR completion. Patients were categorized based on T2EL status. Group 1 included patients with never detected or transient T2ELs (detected at EVAR completion but not after). Group 2 encompassed persistent T2ELs (seen at EVAR completion and again during follow-up) and late T2ELs (detected for the first time at any point during follow-up). Time-to-event analysis was conducted using a time-dependent approach to T2EL status. Primary outcomes included freedom from sac enlargement (SE), aneurysm-related reinterventions, and overall survival.

RESULTS

A total of 803 patients met inclusion criteria. Group 1 included 418 patients (52%), of which 85% had no T2ELs and 15% had transient T2ELs. Group 2 had 385 patients; 23% had persistent T2ELs, and 77% developed a new T2EL. Patients in group 1 had a higher prevalence of smoking (88% vs 83%; P < .001), chronic obstructive pulmonary disease (33% vs 25%; P = .008), chronic kidney disease (13% vs 8%; P = .021), and a higher mean Society for Vascular Surgery score (7 vs 6 points; P = .049). No differences were found in aneurysm diameter or morphology. Mean follow-up was 5 years for the entire cohort. In Group 2, 58 patients (15%) underwent T2EL treatment, most commonly transarterial embolization. At 10 years after EVAR, Group 2 was associated with lower freedom from SE (P < .001) and abdominal aortic aneurysm-related reinterventions (P < .001) and comparable overall survival (P = .42). More T1ELs were detected during follow-up in Group 2 (6 [1%] vs 20 [5%]; P = .004), with 15 (75%) of these detected at a median of 3 years after the T2EL. No difference between groups was observed in explant (0.7% vs 2.1%; P = .130) or aneurysm rupture (0.5% vs 1.3%; P = .269) rates.

CONCLUSIONS

One-half of patients treated with infrarenal EVAR developed persistent/late T2ELs, which are associated with a higher risk of SE and reinterventions. No difference in overall survival or aneurysm rupture risk was seen at 10 years, based on T2EL status or T2EL intervention. A conservative approach to T2ELs may be appropriate for most patients with absent T1ELs or T3ELs.

Ultrasound elastography to quantify average percent pressure-normalized strain reduction associated with different aortic endografts in 3D-printed hydrogel phantoms

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.

CIRSE Standards of Practice on Management of Endoleaks Following Endovascular Aneurysm Repair

BACKGROUND

Endoleaks represent the most common complication after EVAR. Some types are associated with ongoing risk of aneurysm rupture and necessitate long-term surveillance and secondary interventions.

PURPOSE

This document, as with all CIRSE Standards of Practice documents, will recommend a reasonable approach to best practices of managing endoleaks. This will include imaging diagnosis, surveillance, indications for intervention, endovascular treatments and their outcomes. Our purpose is to provide recommendations based on up-to-date evidence, updating the guidelines previously published on this topic in 2013.

METHODS

The writing group was established by the CIRSE Standards of Practice Committee and consisted of clinicians with internationally recognised expertise in endoleak management. The writing group reviewed the existing literature performing a pragmatic evidence search using PubMed to select publications in English and relating to human subjects up to 2023. The final recommendations were formulated through consensus.

RESULTS

Endoleaks may compromise durability of the aortic repair, and long-term imaging surveillance is necessary for early detection and correct classification to guide potential re-intervention. The majority of endoleaks that require treatment can be managed using endovascular techniques. This Standards of Practice document provides up-to-date recommendations for the safe management of endoleaks.

Initial two-day blood pressure management after endovascular aneurysm repair improves midterm outcomes by reducing the incidence of early type II endoleak

OBJECTIVE

The aim of this study was to evaluate midterm outcomes of our novel strategy of postoperative initial 2-day blood pressure management (BPM) after endovascular aneurysm repair (EVAR) for the prevention of subsequent type II endoleak (T2EL) in a single-center series.

METHODS

Between 2008 and 2014, 137 patients who underwent EVAR for abdominal aortic aneurysm (AAA) were reviewed. Starting from 2013, the mean blood pressure was maintained between 75 and 90 mmHg for the initial 24 hours after EVAR followed by systolic pressure controlled below 120 mmHg during the next 24 hours in the treatment group (n = 76). The incidence of T2EL detected at 7 days, reintervention, and AAA sac diameter up to 5 years after EVAR were compared with those of the control group comprising of 60 consecutive patients who underwent standard EVAR without BPM prior to 2013.

RESULTS

Between the treatment group and the control group, significant differences were achieved in the incidence of T2EL at 7 days (19.7% vs 40.0%; P = .009), a mean decrease of AAA sac diameter at 1-year (-5.1 ± 4.9 vs -2.2 ± 6.7 mm; P = .013) and 2-year (-5.4 ± 7.7 vs -1.7 ± 10.8 mm; P = .045). In addition, there was a significant decrease in the incidence of T2EL detected at 7 days with the use of the Gore Excluder with 22.7% in the treatment group vs 80.0% in the control group (P < .001), which resulted in a significant decrease in the aneurysm sac diameter up to 4 years after EVAR. Survival rate without AAA sac enlargement at 5 years after EVAR (83.0% vs 70.0%; P = .021) in the treatment group was significantly higher than that of the control group, whereas no significant differences were observed in the freedom rates of reintervention, T2EL-related reintervention, and all-cause mortality between the groups.

CONCLUSIONS

Postoperative initial 2-day BPM had a preventive effect on AAA sac enlargement until midterm periods, by reducing the incidence of T2EL at 7 days after EVAR. The usage of Gore Excluder under BPM was especially associated with sustained positive effects until the midterm follow-up.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Midterm outcomes of physician-modified endovascular stent grafts for the treatment of complex abdominal aortic aneurysms in Korea: a retrospective study

Purpose

Physician-modified endovascular stent grafts (PMEG) are a good treatment option for complex abdominal aortic aneurysms (AAAs), especially in high-risk patients not amenable to open repair, and when commercial fenestrated devices are not available. We report our single-center experience with PMEG for the treatment of complex AAAs.

Methods

We retrospectively reviewed patients who underwent PMEG repair for AAA from November 2016 to September 2020 at our institution. Demographic data, anatomic characteristics, perioperative and postoperative outcomes, major adverse events, and 30-day mortality were analyzed.

Results

We identified 12 patients who underwent PMEG for complex AAA. The mean age was 74 years and the mean maximal AAA diameter was 58.1 mm. Indications for treatment included 4 impending or contained ruptures, 2 mycotic aneurysms, and 6 symptomatic cases. The technical success rate was 91.7%. Aneurysm sac regression was observed in 7 patients (58.3%), including 2 cases of complete regression. There was 1 aneurysm-related mortality at 3 months due to mycotic aneurysm. Also, there was 1 postoperative complication case of transient renal failure requiring temporary dialysis. At 1 year, there was 1 branch occlusion from the initial failed cannulation case and 2 type 1A endoleaks, and there was 1 case of open explantation.

Conclusion

PMEG showed a low technical failure rate and acceptable midterm stent durability and sac stability, comparable to conventional endovascular aneurysm repair. Despite the small number of cases, there was a tendency for a high sac regression rate, although longer follow-up is needed.

Review of Clinical Applications of Dual-Energy CT in Patients after Endovascular Aortic Repair

Abdominal aortic aneurysms (AAAs) are a significant cause of mortality in developed countries. Endovascular aneurysm repair (EVAR) is currently the leading treatment method for AAAs. Due to the high sensitivity and specificity of post-EVAR complication detection, CT angiography (CTA) is the reference method for imaging surveillance in patients after EVAR. Many studies have shown the advantages of dual-energy CT (DECT) over standard polyenergetic CTA in vascular applications. In this article, the authors briefly discuss the technical principles and summarize the current body of literature regarding dual-energy computed tomography angiography (DECTA) in patients after EVAR. The authors point out the most useful applications of DECTA in this group of patients and its advantages over conventional CTA. To conduct this review, a search was performed using the PubMed, Google Scholar, and Web of Science databases.

Improved Detection of Endoleaks in Virtual Monoenergetic Images in Dual-Energy CT Angiography Following EVAR

OBJECTIVES

The objective of this prospective study was to evaluate the virtual monoenergetic images (VMI) and virtual noncontrast (VNC) phase in the detection of endoleaks after endovascular abdominal aortic repair (EVAR). The potential dose reduction of abbreviated examination protocols was calculated.

MATERIALS AND METHODS

Ninety-seven patients after the EVAR procedure were enrolled in this study. An initial single-source noncontrast acquisition was followed by two dual-energy acquisitions (arterial and 60 s delayed). Fast-kVp switching scanner was used. VNC images were reconstructed from the delayed phase. First examination session (reference) included a full triphasic study protocol consisting of true noncontrast (TNC) images and two postcontrast phases, the latter ones presented as classical polyenergetic reconstructions. Reading sessions II and III were performed by two independent and blinded readers evaluating VMIs in abbreviated protocols-biphasic (VNC + arterial, delayed phase), monophasic (VNC + delayed phase). The diagnostic accuracy of sessions II and III was calculated.

RESULTS

The calculated sensitivity of the biphasic protocol with the use of VMIs in endoleak detection was 100%, with a statistically significant increase in the number of endoleaks detected in comparison with the reference study. The monophasic protocol showed 83.33% sensitivity. The use of abbreviated examination protocols led to a decrease in the mean effective dose (ED) of 23.28% (biphasic protocol) and 61.37% (monophasic protocol).

CONCLUSION

The use of VMIs increases the number of endoleaks diagnosed with a possible radiation reduction by up to ¼ (biphasic protocol). Further reduction to a monophasic protocol leads to over 60% dose reduction but with a decrease in diagnostic accuracy.

Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm

The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.

Management of Endoleaks After Elective Infrarenal Aortic Endovascular Aneurysm Repair: A Review

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.

Use of Secondary Iliac Branch Devices after Previous Endovascular Abdominal and Thoraco-Abdominal Aortic Aneurysm Repair

OBJECTIVE

To assess the safety and effectiveness of iliac branch devices (IBDs), as secondary procedure, for the treatment of type Ib endoleak or evolution of iliac artery disease after prior endovascular aortic repair (EVAR) for thoraco-abdominal (TAAAs) or abdominal aortic aneurysms (AAAs).

METHODS

A multicentre observational study of three European centres. The study included 75 patients (age 71 ± 9 years, 96% men) with previous EVAR (n = 64, 85%) or fenestrated or branched (FB) EVAR (n = 11, 15%). Overall, 88 IBDs were implanted to treat aneurysmal iliac artery evolution in 40 (53%) and type Ib endoleak in 35 (47%) cases, respectively. Thirteen (17%) patients received bilateral IBDs. Internal iliac artery (IIA) catheterisation was done through a transaxillary access (n = 82, 93%) or up and over (n = 6, 7%) technique. The primary endpoint was technical success. Secondary endpoints were 30 day major adverse event, early and long term freedom from re-intervention and target vessel instability.

RESULTS

All procedures were technically successful (100%). During hospitalisation, there were four (5%) major adverse events and three (4%) early re-interventions, but no death, stroke, or damage to previous endografts. The median follow up was 47 (interquartile range 42) months, and the five year survival rate was 78 ± 6% with no aortic related death. Cox's regression analysis showed pre-operative renal function impairment (hazard ratio [HR] 3.4; 95% confidence interval [CI] 1.1 - 10.1; p = .033), and primary TAAA repair (HR 6.1; 95% CI 1.6-22.3; p = .006) as independent factors for long term mortality. Freedom from re-interventions was 85 ± 4% at five years with 11 (12%) cases (five endoleaks, four IBD thromboses, two stenoses). IIA instability was reported in three (3%) limbs and freedom from IIA instability was 95 ± 3% after 60 months.

CONCLUSION

Secondary IBD after EVAR is a safe and effective procedure with high technical success and low complication rates. The technique of choice to revascularise the IIA seems not to affect early and follow up results. Long term durability of IBD repair is acceptable with low rates of IIA re-intervention.

The impact of completion and follow-up endoleaks on survival, reintervention, and rupture

OBJECTIVE

Endoleaks may be seen at case completion of endovascular abdominal aortic aneurysm repair (EVAR), and the presence of an endoleak may impact outcomes. However, the clinical implications of various endoleaks seen during follow-up is not well-described. Therefore, we studied the impact of endoleaks at completion and at follow-up on mid-term outcomes.

METHODS

We reviewed patients who underwent EVAR from 2003 to 2016 within the Vascular Quality Initiative-Medicare database and identified patients with endoleak at procedure completion and during follow-up, excluding those presenting with rupture. We stratified cohorts by presence of completion and follow-up endoleak subtypes. The primary outcome was 5-year survival, and secondary outcomes included 5-year freedom from reintervention and freedom from rupture. We used Kaplan-Meier estimates and log-rank tests to analyze differences in time-to-event endpoints.

RESULTS

Of 21,745 patients with completion endoleak data, 5085 (23%) had an endoleak. Compared with those without endoleak, those with type I endoleaks had lower 5-year survival (69% vs 75%; P < .001), type II endoleaks had higher survival (79%; P < .001), and types III, IV, and indeterminate were not statistically different (73%, 73%, and 75%, respectively). Freedom from reintervention for types I and III endoleaks were significantly lower than no endoleak cohort (I: 76%; P < .001; III: 72%; P < .001 vs 83%), but freedom from rupture was higher for those with type II and III endoleak (95% and 97% vs 94%; P < .001). Of 14,479 patients with detailed follow-up endoleak data, 2290 (16%) had an endoleak. Compared with those without endoleak, types I and III had significantly lower 5-year survival (I: 80%; P = .002; III: 66%; P < .001 vs 84%), but there were no differences for types II (82%) and indeterminate (77%). Those with any type of follow-up endoleak had lower 5-year freedom from reintervention (I: 70%; P < .001; II: 76%; P = .006; III: 36%; P < .001; indeterminate: 60%; P = .007 vs 84%), and lower freedom from rupture (I: 92%; P < .001; II: 91%; P = .16; III: 88%; P = .01; indeterminate: 90%; P = .11 vs 94%).

CONCLUSIONS

Compared with patients with no endoleak, those with type I completion endoleaks have lower 5-year survival and freedom from reintervention. Patients with types I and III follow-up endoleaks also have lower survival, and any endoleak at follow-up is associated with lower freedom from reintervention and freedom from rupture. These data highlight the importance of careful patient selection and close postoperative follow-up after EVAR, as the presence of endoleaks, specifically type I and III, over time portends worse outcomes.

Endoleak Detection after Endovascular Aortic Repair via Coded-Excitation Ultrasound-A Feasibility Study

Endoleaks are the most common complication after endovascular aortic repair (EVAR). Their correct identification is one of the main objectives of surveillance protocols after EVAR. So far, computed tomography angiography (CTA), contrast-enhanced (CEUS) and Duplex ultrasound (DUS), as well as magnetic resonance angiography, have been investigated for their ability to detect endoleaks. In general, all technologies have distinct benefits and disadvantages, with CTA and CEUS emerging as the reference standard for surveillance after EVAR. However, they are both contrast-enhancer-dependent, and CTA additionally exposes patients to ionizing radiation. In the present study, we investigated B-Flow, a type of coded-excitation ultrasound that was specifically designed to optimize the visualization of blood flow, for its ability to detect endoleaks, and compared its performance to CEUS, CTA, and DUS. In total, 34 patients were included in the analysis that accumulated in 43 distinct B-Flow investigations. They underwent a total of 132 imaging investigations. Agreement between B-Flow and other imaging modalities was high (>80.0%), while inter-method reliability can be interpreted as good. However, with B-Flow, six and one endoleaks would have been missed compared to CEUS and CTA, respectively. Regarding endoleak classification, all metrics were lower but retained an adequate level of comparison. In a subset of patients requiring intervention, B-Flow had 100% accuracy regarding both endoleak detection and classification. Ultrasonography enables endoleak detection and classification without the need for pharmaceutical contrast enhancement or radiation. Ultrasound coded-excitation imaging in the application of B-Flow could further simplify surveillance after EVAR by offering adequate accuracy without requiring intravenous contrast enhancement. Our findings may promote subsequent investigations of coded-excitation imaging for endoleak detection and classification in the surveillance after EVAR.

Identifying Patients at High Risk for Post-EVAR Aneurysm Sac Growth

PURPOSE

Post-EVAR (endovascular aneurysm repair) aneurysm sac growth can be seen as therapy failure as it is a risk factor for post-EVAR aneurysm rupture. This study sought to identify preoperative patient predictors for developing post-EVAR aneurysm sac growth.

MATERIAL AND METHODS

A systematic review was conducted to select potential predictive preoperative factors for post-EVAR sac growth (including a total of 34.886 patients), which were evaluated by a retrospective single-center analysis of patients undergoing EVAR between 2009 and 2019 (N=247) with pre-EVAR computed tomography scans and at least 1 year follow-up. The primary study outcome was post-EVAR abdominal aortic aneurysm (AAA) sac enlargement (≥5 mm diameter increase). Multivariate Cox regression and Kaplan-Meier survival curves were constructed.

RESULTS

Potential correlative factors for post-EVAR sac growth included in the cohort analysis were age, sex, anticoagulants, antiplatelets, renal insufficiency, anemia, low thrombocyte count, pulmonary comorbidities, aneurysm diameter, neck diameter, neck angle, neck length, configuration of intraluminal thrombus, common iliac artery diameter, the number of patent lumbar arteries, and a patent inferior mesenteric artery. Multivariate analysis showed that infrarenal neck angulation (hazard ratio, 1.014; confidence interval (CI), 1.001-1.026; p=0.034) and the number of patent lumbar arteries (hazard ratio, 1.340; CI, 1.131-1.588; p<0.001) were associated with post-EVAR growth. Difference in estimated freedom from post-EVAR sac growth for patients with ≥4 patent lumbar arteries versus <4 patent lumbar arteries became clear after 2 years: 88.5% versus 100%, respectively (p<0.001). Of note, 31% of the patients (n=51) with ≥4 patent lumbar arteries (n=167) developed post-EVAR sac growth. In our cohort, the median maximum AAA diameter was 57 mm (interquartile range [IQR] = 54-62) and the median postoperative follow-up time was 54 months (IQR = 34-79). In all, 23% (n=57) of the patients suffered from post-EVAR growth. The median time for post-EVAR growth was 37 months (IQR = 24-63). In 46 of the 57 post-EVAR growth cases (81%), an endoleak was observed; 2.4% (n=6) of the patients suffered from post-EVAR rupture. The total mortality in the cohort was 24% (n=60); 4% (n=10) was AAA related.

CONCLUSIONS

This study showed that having 4 or more patent lumbar arteries is an important predictive factor for postoperative sac growth in patients undergoing EVAR.

CLINICAL IMPACT

This study strongly suggests that having 4 or more patent lumbar arteries should be included in preoperative counseling for EVAR, in conjunction to the instructions for use (IFU).

Treatment of Aortocaval Fistula Secondary to Abdominal Aortic Aneurysm: A Systematic Review

BACKGROUND

Aortocaval fistula (ACF) secondary to an abdominal aortic aneurysm is a rare complication, inadvertently caused by a rupture into the inferior vena cava. Different treatment modalities have been applied toward the repair of such lesions, including open surgical and endovascular repair. The aim of this study was to report on ACF treatment and to analyze its early and mid-term outcomes.

METHODS

A systematic search of the English medical literature published between 2000 and 2022 was undertaken, using PubMed, SCOPUS, and CENTRAL databases as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 guidelines. A study protocol was registered in PROSPERO (CRD42022329058). Studies reporting on primary ACF outcomes following open surgical or endovascular repair were included. The ROBINS-I tool was applied for risk of bias assessment. Outcomes included technical success, 30-day and mid-term survival, endoleak following endovascular repair, and reintervention rates.

RESULTS

In total, 110 case studies, incorporating 196 patients (mean age; 66.2 years, males 96%) were included. Open surgical repair was applied in 78% (153/196). From the available data, technical success rate for each modality was 99% (152/153) and 100% (43/43), respectively. Open and endovascular repair demonstrated 87.5% (126/144) and 97.6% (42/43) 30-day survival, respectively, while mid-term survival was 86% (74/86) and 95.2% (20/21), respectively (medial follow-up: 14 months [1-54 months]). Endoleaks were reported in 19 endovascular cases (39.5%). Type II endoleak was the most frequent with a rate at 32.5% (14/43). Reintervention rates were 2.5% (4/151) and 35.7% (15/42) for open and endovascular repair, respectively.

CONCLUSIONS

Only few case studies were published on the treatment of this rare condition, while almost all invasive procedures were performed in males. Management of ACF repair with both open and endovascular approach was associated with excellent technical success rate and acceptable early and mid-term survival outcomes. Reintervention remained an issue for patients who were managed endovascularly.

Systematic review and network meta-analysis of pre-emptive embolization of the aneurysm sac side branches and aneurysm sac coil embolization to improve the outcomes of endovascular aneurysm repair

Objective

Previous reports have revealed a high incidence of type II endoleak (T2EL) after endovascular aneurysm repair (EVAR). The incidence of T2EL after EVAR is reduced by pre-emptive embolization of aneurysm sac side branches (ASSB) and aneurysm sac coil embolization (ASCE). This study aimed to investigate whether different preventive interventions for T2EL were correlated with suppression of aneurysm sac expansion and reduction of the re-intervention rate.

Methods

The PubMed, Web of Science, MEDLINE and Embase databases, and conference proceedings were searched to identify articles on EVAR with or without embolization. The study was developed in line with the Participants, Interventions, Comparisons, Outcomes, and Study design principles and was conducted and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We used network meta-analysis based on multivariate random-effects meta-analysis to indirectly compare outcomes of different strategies for embolization during EVAR.

Results

A total of 31 studies met all inclusion criteria and were included in the qualitative and quantitative syntheses. The included studies were published between 2001 and 2022 and analyzed a total of 18,542 patients, including 1,882 patients who received prophylactic embolization treatment during EVAR (experimental group) and 16,660 who did not receive prophylactic embolization during EVAR (control group). The effect of pre-emptive embolization of the inferior mesenteric artery (IMA) (IMA-ASSB) in preventing T2EL was similar (relative risk [RR] 1.01, 95% confidence interval [CI] 0.38–2.63) to the effects of non-selective embolization of ASSB (NS-ASSB) and ASCE (RR 0.88, 95% CI 0.40–1.96). IMA-ASSB showed a better clinical effect in suppressing the aneurysm sac expansion (RR 0.27, 95% CI 0.09–2.25 compared with NS-ASSB; RR 0.93, 95% CI 0.16–5.56 compared with ASCE) and reducing the re-intervention rate (RR 0.34, 95% CI 0.08–1.53 compared with NS-ASSB; RR 0.66, 95% CI 0.19–2.22 compared with ASCE). All prophylactic embolization strategies improved the clinical outcomes of EVAR.

Conclusion

Prophylactic embolization during EVAR effectively prevents T2EL, suppresses the aneurysm sac expansion, and reduces the re-intervention rate. IMA embolization demonstrated benefits in achieving long-term aneurysm sac stability and lowering the risk of secondary surgery. NS-ASSB more effectively reduces the incidence of T2EL, while IMA embolization alone or in combination with ASCE enhances the clinical benefits of EVAR. In addition, as network meta-analysis is still an indirect method based on a refinement of existing data, more studies and evidence are still needed in the future to establish more credible conclusions.

Long-term Outcomes Associated With Open vs Endovascular Abdominal Aortic Aneurysm Repair in a Medicare-Matched Database

IMPORTANCE

Endovascular aneurysm repair is associated with a significant reduction in perioperative mortality and morbidity compared with open aneurysm repair in the treatment of abdominal aortic aneurysm. However, this benefit decreases over time owing to increased reinterventions and late aneurysm rupture after endovascular repair.

OBJECTIVE

To compare long-term outcomes of endovascular vs open repair of abdominal aortic aneurysm.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter retrospective cohort study used deidentified data with 6-year follow-up from the Medicare-matched Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database. Patients undergoing first-time elective endovascular or open abdominal aortic aneurysm repair from 2003 to 2018 were propensity score matched. Patients with ruptured abdominal aortic aneurysm, concomitant procedures, or prior history of abdominal aortic aneurysm repair, were excluded. Data were analyzed from January 1, 2003, to December 31, 2018.

EXPOSURES

First-time elective endovascular or open repair for abdominal aortic aneurysm.

MAIN OUTCOMES AND MEASURES

The primary long-term outcome of interest was 6-year all-cause mortality, rupture, and reintervention. Secondary outcomes included 30-day mortality and perioperative complications.

RESULTS

Among a total of 32 760 patients (median [IQR] age, 75 [70-80] years; 25 706 [78.5%] men) who underwent surgical abdominal aortic aneurysm repair, 28 281 patients underwent endovascular repair and 4479 patients underwent open repair. After propensity score matching, there were 2852 patients in each group. Open repair was associated with significantly lower 6-year mortality compared with endovascular repair (548 deaths [35.6%] vs 608 deaths [41.2%]; hazard ratio [HR], 0.83; 95% CI, 0.74-0.94; P = .002), with increases in mortality starting from 1 to 2 years (84 deaths [4.3%] vs 126 deaths [6.7%]; HR, 0.63; 95% CI, 0.48-0.83; P = .001) and 2 to 6 years (211 deaths [25.8%] vs 241 deaths [30.6%]; HR, 0.73; 95% CI, 0.61-0.88; P = .001). Open repair, compared with endovascular repair, also was associated with significantly lower rates of 6-year rupture (117 participants [5.8%] vs 149 participants [8.3%]; HR, 0.76; 95% CI, 0.60-0.97; P < .001) and reintervention (190 participants [11.6%] vs 267 participants [16.0%]; HR, 0.67; 95% CI, 0.55-0.80; P < .001). Open repair was associated with significantly higher odds of 30-day mortality (OR, 3.56; 95% CI, 2.41-5.26; P < .001) and complications.

CONCLUSIONS AND RELEVANCE

These findings suggest that overall mortality after elective abdominal aortic aneurysm repair was higher with endovascular repair than open repair despite reduced 30-day mortality and perioperative morbidity after endovascular repair. Endovascular repair additionally was associated with significantly higher rates of long-term rupture and reintervention. These findings emphasize the importance of careful patient selection and long-term follow-up surveillance for patients who undergo endovascular repair.

Predictive value of elliptical neck parameters and oversizing ratio for type Ia endoleaks after endovascular aneurysm repair

OBJECTIVE

To assess the predictive value of elliptical geometric parameters regarding type IA endoleak (T1AEL) after endovascular aneurysm repair (EVAR) and investigate optimal range of oversizing ratio (OSR) in patients with elliptical aneurysmal neck.

METHODS

In this propensity-score matched case-control study, case patients were those diagnosed with T1AEL, control patients were those who did not have T1AEL after EVAR in the same period from 2012 to 2018. Geometric and oversizing parameters were compared based on both 2D and 3D measurement. Net reclassification improvement (NRI) was used to measure prediction increment of elliptical model (major axis OSR, neck length and severe neck angulation (SNA)) compared to conventional model (OSR 2D, neck length and SNA).

RESULTS

Nineteen case patients and 111 control patients were included. The median OSR 2D of T1AEL patients were 17% (15%-22%), but the median major axis OSR were only 7% (5%-12%). Among geometric parameters, axis difference had the highest area under the curve (AUC) of 0.74 (95%CI 0.63-0.84) in predicting T1AEL. As for elliptical oversizing parameters, major axis OSR had an AUC of 0.89 (95%CI 0.78-0.97) with a cut-off value of 13%. Elliptical model had higher discriminating ability in T1AEL compared to conventional model (AUC 0.91 vs 0.86, P=0.045), with improved reclassification ability (NRI 27.93%, 95% CI 19.22%-36.64%, P<0.0001).

CONCLUSION

Elliptical aneurysmal neck, assessed by axis difference, is associated with an increased risk of T1AEL. Calculation of oversizing based on major axis for at least 13% can significantly reduce the risk of T1AEL in patients with elliptical aneurysmal neck.

Safety and Validity of the Proposed European Society for Vascular Surgery Infrarenal Endovascular Aneurysm Repair Surveillance Protocol: A Single Centre Evaluation

OBJECTIVE

Long term surveillance after endovascular aneurysm repair (EVAR) is essential to detect late complications, but there is variation in practice. The European Society for Vascular Surgery (ESVS) made a recommendation for a new surveillance protocol; one element involves risk stratifying patients depending on sac size reduction and presence of endoleak at their 30 day computed tomography angiogram into low risk groups (delayed imaging to five years) or higher risk groups (continue with the current protocol). The aim was to test this suggested protocol retrospectively within an EVAR patient cohort.

METHODS

Data on EVARs performed from October 2009 to October 2019 were collected. Information gathered from an existing surveillance programme was used to assess the proposed ESVS protocol. All patients who underwent re-intervention were reviewed to see whether adopting the proposed ESVS protocol would have detected these events.

RESULTS

In total, 309 procedures were included. Altogether, 219 of these patients had no endoleak (70.9%) and 86 had a type II (27.8%) endoleak. Only four developed a type I or III endoleak. No patient in the low risk cohort (no initial endoleak or sac shrinkage > 1 cm) required secondary intervention. Five year follow up data were available for 103 patients. In the type II endoleak group, there were 28 secondary interventions in 22 patients. No patient experienced a ruptured aneurysm within five years post-operatively. Had the proposed ESVS protocol been followed, all patients requiring a secondary intervention or with increasing sac size would have been detected/captured. Further, adherence to the ESVS guidelines would have resulted in 103 patients with a five year follow up history qualifying for reduced surveillance. A further 120 patients who had reached the three and four year follow up timepoints could have qualified for a reduced surveillance, reducing imaging cost further.

CONCLUSION

Adopting the proposed ESVS EVAR surveillance protocol safely identified "low risk" patients who did not go on to require a secondary intervention. These patients could benefit from reduced surveillance scanning.

Surgical Findings and Outcomes of Endotension following Endovascular Aneurysm Repair

BACKGROUND

Endotension is one of the detrimental complications after endovascular aneurysm repair (EVAR) and surgical management has been considered as standard of care. However, there is a paucity of data regarding the findings and outcomes of such surgical intervention. The aim of this study was to investigate intraoperative findings and outcomes of surgical treatment for endotension after EVAR.

METHODS

Between January 2005 and October 2018, of the 708 patients who underwent EVAR for aneurysm aortic aneurysm; 12 patients (mean age of 76.1; range 66-88) who underwent open repair for endotension were retrospectively analyzed. The anatomical characteristics of the aorta and surgical findings were reviewed. The rates of early and late procedural complications, and overall mortality were evaluated.

RESULTS

The median interval between the EVAR and surgical conversion was 45.9 months (range 17.1-46.9). Three of the twelve patients underwent emergency surgery due to aneurysm rupture. The median aneurysm sac size, the proximal neck diameter, and the proximal neck length before EVAR were 64 mm, 23.5 mm, and 30.5 mm, respectively, that changed before open repair to 93.5 mm (p = .02), 25 mm (p = .011), and 23 mm (p = .003), respectively. In four of the twelve patients, radiographically undetected endoleak was identified during surgery to be Type Ia, Ib, II, and III, respectively. The rates of early and late procedural complications, and overall mortality were 8.3%, 8.3% and 8.3%, respectively.

CONCLUSIONS

Patients with endotension have a risk of delayed endoleak and aneurysm rupture; secondary intervention should be performed in such cases to prevent fatal complications. Surgical treatment appears to be a curative treatment for endotension with favorable outcomes. In addition, the possibility of an undetected endoleak should be considered as a potential cause of endotension.

Effect of Stent-Graft Active Fixation and Oversizing on Aortic Neck Dilation After Endovascular Aneurysm Exclusion For Infrarenal Aortic Aneurysm

INTRODUCTION

Aortic neck dilation post endovascular aneurysm repair (EVAR) has been implicated in the long-term development of endoleak and the subsequent re-intervention. Optimal endograft sizing is a vital aspect to successful repair. This study looked at percentage of graft oversizing as well as type of fixation on aortic neck dilation.

METHODS

We retrospectively evaluated all EVARs completed at Loyola's University from 2006 to 2015 after IRB approval. Patients without follow-up scans within a year were excluded. We collected demographics, comorbidities, graft type, size, aortic neck diameter, maximum sac size diameters from the pre-operative and follow-up scans. We reviewed and collected data on 432 patients but analyzed 154. We measured the largest aortic diameter on axial images 1 cm above and 1 cm below the lowest renal artery. Change in supra and infrarenal aortic measurements were evaluated by calculating the mm difference from each scan compared to the pre-operative scan. Linear mixed effects models were used to estimate patients' mean differences over time.

RESULTS

We compared three groups of neck fixation grafts. Those with active suprarenal fixation had a significant change in suprarenal aortic diameter at four-year follow-up (1.86 mm, CI:0.65-3.06), compared to those with active infrarenal (0.22 mm, CI: -0.67 to -1.11) or passive suprarenal fixation (1.52 mm, CI: -0.11 to -3.15) (Fig. 1). Those with active suprarenal fixation were the only ones to have significant increase in suprarenal aortic diameter (P = 0.0026). Degree of oversizing was also divided into three groups. Oversizing by <10% had less impact on the suprarenal aorta than >15% oversizing at 4 years (0.41 mm, CI: -0.31 to -1.14 vs. 3.26 mm, CI: 1.63-4.88, P < 0.001) (Fig. 2). Oversizing had a more pronounced effect on the infrarenal aorta: 3.01 mm, CI: 2.18-3.83; 5.95 mm, CI: 3.26-8.64; and 5.05 mm, CI: 3.41-6.69 for <10%, 10-15%, and >15% oversizing at four years, respectively.

CONCLUSION

Stent-grafts with active fixation below the renal arteries as well as oversizing by <10% seem to have the least effect on aortic neck dilation over time. These factors should be considered when performing EVARs, as aortic neck dilation could lead to endoleak and need for further intervention. Further research defining the optimal stent-graft type, self-expanding versus balloon expandable, type of fixation and degree of oversizing.

Risk Factors for Abdominal Compartment Syndrome After Endovascular Repair for Ruptured Abdominal Aortic Aneurysm: A Case Control Study

OBJECTIVE

Ruptured abdominal aortic aneurysms (rAAA) are treated by endovascular aneurysm repair (rEVAR) increasingly often. Despite rEVAR being a minimally invasive method, abdominal compartment syndrome (ACS) remains a significant post-operative threat. The aim of this study was to investigate risk factors for ACS after rEVAR, including aortic morphological features.

METHODS

The Swedish vascular registry (Swedvasc) was assessed for ACS after rEVAR in the period 2008 - 2015. All patients identified were compared with controls (i.e., patients who did not develop ACS after rEVAR), matched by centre and repair date. Case records were reviewed, and radiology images analysed in a core laboratory. Comparisons were performed with respect to physiological and radiological risk factors.

RESULTS

The study population consisted of 40 patients with ACS and 68 controls. Pre-operatively, patients with ACS had a lower blood pressure (BP) than controls (median 70 mmHg vs. 97 mmHg; p < .001). Intra-operatively, they had aortic balloon occlusion more often (55.0% vs. 10.3%; p < .001) and received more transfusions than controls (median nine units of packed red blood cells [pRBC] vs. two units; p < .001). Ninety-seven per cent of those who developed ACS had a pre-operative BP < 70 mmHg, aortic balloon occlusion, or received more than five pRBC unit transfusions. Treatment outside the instructions for use did not differ between patients and controls (57.5% vs. 54.4%; p = .84), and neither did the pre-operative patency of the inferior mesenteric artery (57.1% vs. 63.9%; p = .52) nor the number of visible lumbar arteries on pre-operative imaging (2 vs. 4; p = .014). In multivariable logistic regression, the number of intra-operative transfusions were predictive of ACS (p < .001), while pre-operative hypotension (p = .32) and aortic balloon occlusion (p = .018) were not.

CONCLUSION

ACS after rEVAR is mainly associated with physiological factors and is unlikely to develop without the presence of a pre-operative BP < 70 mmHg, the need for an aortic occlusion balloon, or more than five intra-operative pRBC unit transfusions. Treatment outside the IFU or any other morphological factor were not associated with a risk of ACS.

Endotension: What do we know and not know about this enigmatic complication of endovascular aneurysm repair

As the use of endovascular approaches to treat aneurysm repair continues to increase, more and more patients have been identified with endoleaks. Five types of endoleaks have been defined. Endotension, or type V endoleak, remains controversial owing to its variable definition across studies and the range of proposed treatments. Thus, we performed a review of the reported studies to summarize the diagnosis and treatment of this rare complication after endovascular aneurysm repair to determine what we do and do not know about this rare form of endoleak. The presence of an endoleak places patients at an increased risk of aneurysm sac enlargement and potential rupture. Although additional research is essential and yet difficult to perform, we sought to provide a guide for the management of this perplexing endoleak known as endotension.

Complications of endo-vascular aortic repair for abdominal aortic aneurysm: A retrospective single-centre experience

Background

Endovascular aortic repair (EVAR) is obviously less invasive than open aortic repair (OAR) for the treatment of infra-renal abdominal aortic aneurysm (AAA). However, it is not free of complications which can potentially result in severe morbidity or even mortality. The purpose of this study was to share our single-center experience with stent-graft related and systemic complications associated with EVAR.

Methods

Patients with infra-renal AAA treated by elective and emergency EVAR between March 2014 and November 2020 were retrospectively identified. Demographic data, risk factors, American Society of Anesthesiologists (ASA) score, systemic complications, stent-graft related complications, surgical site complications, 30-day mortality, late EVAR related mortality, estimated blood loss, intensive care unit (ICU) length of stay (LOS), hospital LOS and follow-up durations were collected and analyzed.

Results

A total of 43 patients underwent EVAR during the period of study. There were 42 males (97.7%) and 1 female (2.3%). The mean age was 68.8 ± 6.2 years. Elective EVAR was performed in 36 (83.7%) and emergency EVAR in 7 (16.3%). Technical success was achieved in 42 patients (100%) with no conversion to OAR. Stent-graft related complications were (21.0%) endoleaks, (2.3%) graft limb occlusion, (0%) graft infection, and (2.3%) rupture-EVAR. Systemic complications were (2.3%) myocardial infarction (MI), (2.3%) stroke, (2.3%) spinal cord injury (SCI), (2.3%) respiratory failure, (19.0%) wound complications, and (2.3%) acute lower limb ischemia (ALI). The 30-day mortality was (2.3%) due to perioperative MI and the late graft related mortality was (2.3%) due to rupture-EVAR.

Conclusion

EVAR showed a high technical success rate with no conversion to OAR. The most common complications were type II and type I endoleaks followed by graft limb occlusion. The 30-day mortality was 2.3% due to perioperative MI. Only one late stent-graft related mortality was registered due to rupture-EVAR.

Early periaortic hematoma development after EVAR in the presence of severely calcified and modestly conical-shaped aortic neck: A potential trigger for sudden aneurysm progression toward rupture

OBJECTIVE

The aim of this report is to present a singular case of early post-endovascular aneurysm repair abdominal aortic aneurysm rupture and discuss the possible etiopathogenic mechanism promoting the sudden aneurysm progression toward rupture.Methods/Results: An 84-year-old man was submitted to endovascular aneurysm repair via second-generation endograft (Cordis-Incraft Stent-graft) during which, the left occluded common iliac artery was recanalized via balloon-expandable covered-stent-graft (Atrium-Advanta-V12). The aneurysm presented a severely calcified and modestly conical-shaped aortic-neck. The post-operative course was complicated by a broncho pneumonic infiltrate and a CT scan performed two weeks postoperatively accidentally revealed a relatively small hematoma surrounding the aortic wall. No active bleeding, endoleak, or aneurysm increase in diameter was documented. Nevertheless, the patient remained closely monitored. Three days later, he suffered from abdominal aortic aneurysm rupture. A CT scan revealed an arterial wall tear at the neck level. Intra-operatively the reanalyzed common iliac artery was intact and a good endograft-sealing was confirmed. Following this event, small lumbar arteries suture saccotomy was performed. The patient eventually died of multiorgan failure one month later.

CONCLUSIONS

The apparently "self-limiting" post-endovascular aneurysm repair CT-scan finding of periaortic hematoma may have represented a potential trigger for abdominal aortic aneurysm rupture. The possibility of developing undetected aortic lesions during endovascular aneurysm repair, specifically in the presence of potentially "at risk" anatomical conditions, should always be considered.

Aortic Rupture during Endovascular Aneurysm Repair. Report of Our Experience and Review of the Literature

Background  Aortic neck wall rupture during endovascular repair of abdominal aortic aneurysms (EVAR) is an underreported potentially fatal complication. Only a few cases have been reported. The main cause of this complication is repeated attempts at balloon inflation or overdilation to treat an intraoperative Type 1a endoleak. We report three cases complicated by procedure-related aortic neck wall rupture during EVAR. We also review the literature regarding the causes and outcomes of this complication.

Methods  Medical records of all patients undergoing EVAR between January 2009 and March 2019 were retrospectively reviewed.

Results  Overall, 824 EVAR procedures were performed, and rupture of the aortic neck wall was observed in three patients. In all cases, a Type 1a endoleak was observed and, in all cases, repeated ballooning attempts had been performed to resolve the endoleaks. In all cases, conversion to open repair was performed and all patients survived.

Conclusion  In cases of Type 1a endoleak, a maximum of two ballooning attempts should be performed even if a Type 1a endoleak persists. In case of intraoperative aortic neck wall rupture, control of the hemorrhage should be achieved immediately by advancing the balloon above the site of rupture. Emergency surgical conversion in case of hemodynamic stability is the first choice. According to the literature, emergency surgical conversion, especially in cases of endograft with suprarenal fixation, is associated with significant morbidity and mortality rates, mainly due to hemorrhage and to the length of the procedure required to repair the aortic neck wall injury.

Does a previous aortic endograft confer any protective effect during abdominal aortic aneurysm rupture? Systematic review and meta-analysis of comparative studies

OBJECTIVES

Whether prior endovascular aneurysm repair confers a protective effect in patients with ruptured abdominal aortic aneurysm (rAAA) is not known. We aimed to systematically review and compare the outcomes of rAAA in patients with and without prior endovascular aneurysm repair.

METHODS

We performed a systematic review that conformed to the Preferred Reporting Items for Systematic Reviews and Meta-analysis. We selected studies comparing the outcomes in patients with rAAA after prior endovascular aneurysm repair (group 1) and those with de novo rAAAs (group 2). We conducted a proportion meta-analysis of perioperative mortality and obtained summary estimates of odds ratios (ORs) and 95% confidence intervals (CIs) using random-effects models.

RESULTS

We included four studies (retrospective observational studies) in quantitative synthesis reporting a total of 719 patients (group 1 (89) group 2 (630)). The perioperative mortality in groups 1 and 2 was 30.4% and 41%, respectively, and there was no statistical significant difference between the groups (OR 0.66, 95% CI 0.30-1.43, P = 0.29, I²=58%). However, patients presenting with rAAA following previous endovascular aneurysm repair were more hemodynamically stable (OR 0.33, 95% CI 0.12-0.90, P = 0.03, I²=74%). The choice between endovascular or open surgery treatment in group 1 did not affect the perioperative mortality (OR 1.12, 95% CI 0.41-3.04 P = 0.82, I²=0%). Endoleak types I and III were the main causes of rAAA in group 1.

CONCLUSIONS

Perioperative mortality was similar for rAAA either de novo or after prior endovascular aneurysm repair. However, ruptures in patients with prior endovascular aneurysm repair presented hemodynamically more stable.

Multicenter experience in translumbar type II endoleak treatment in the hybrid room with needle trajectory planning and fusion guidance

OBJECTIVE

The objective of this study was to evaluate the efficacy of treating type II endoleaks (T2Ls) after aortic endovascular repair with image guidance translumbar puncture using intraoperative cone beam computed tomography with preprocedure computed tomography angiography fusion in hybrid operating rooms.

METHODS

Twenty-six consecutive T2L patients in three different institutions were treated between March 2015 and September 2017 by direct translumbar puncture of the abdominal aortic aneurysm (AAA) sac after previous endovascular aortic repair. All patients were treated at a single setting in a cardiovascular hybrid operating room with a workstation featuring needle trajectory planning and guidance software. Aneurysm sac size change from the index treatment, freedom from recurrent endoleak after treatment, demographics, risk factors, and procedure factors were analyzed with univariate analysis.

RESULTS

All patients (N = 26; 19 male, 7 female; age range, 59-95 years; mean body mass index, 27.44 ± 3.06 kg/m²) underwent treatment for AAA sac expansion or symptoms. Four patients had failed to respond to previous catheter-directed T2L treatment. The most common risk factors included hypertension, hypercholesterolemia, coronary artery disease, tobacco use, and diabetes. Time to initial endoleak diagnosis ranged from 2 to 1914 days (average, 404 days). Aneurysm size after initial repair was 60.3 ± 7.5 mm; sac size had increased 10.1 ± 6.5 mm at the time of treatment. Onyx (Medtronic, Irvine, Calif) or glue (n-butyl cyanoacrylate) and coil embolization was used in 20 cases, and 6 patients were treated with coiling alone. There was no difference between the patients treated with coils alone and those treated with coils or glue (P > .05) in terms of freedom from failure. Total procedure time was 75.9 ± 40.7 minutes; contrast material volume, 19.9 ± 29 mL; fluoroscopy time, 13.74 ± 12.2 minutes; and radiation dose, 121.16 ± 167.7 mGy. After embolization, the mean sac diameter decreased by 2.2 mm to 67.5 ± 9.8 mm. Average follow-up period was 214 days. In 19 patients, the sac reduced in size between 0.2 and 19.1 mm per 100 days; in 2 patients, there was continued AAA expansion (3.4-4.3 mm per 100 days); there was no change in the sac size in 5 patients after the procedure. There were no AAA ruptures during the study period. Once T2L was treated, the recurrence rate was low at 11.5%.

CONCLUSIONS

This initial multicenter evaluation of the effectiveness of fusion image-guided translumbar obliteration of T2L demonstrated that the technique was effective at all three study centers and showed excellent efficacy to reduce AAA sac size. This may become a more effective and efficient method of treating T2L compared with transarterial or transcaval embolization because of its high success rate and technical ease.

Endovascular Aortic Aneurysm Repair without Type 2 Endoleak Using Concomitant N-Butyl-2-Cyanoacrylate Injection into the Abdominal Aortic Aneurysm Sac

BACKGROUND

The aim of this study was to evaluate our new method to occlude target lumber arteries using N-butyl-2-cyanoacrylate (NBCA) during endovascular aneurysm repair (EVAR) for prevention of type 2 endoleak (T2E).

METHODS AND RESULTS

Between 2013 and 2018, 176 patients who underwent EVAR for abdominal aortic aneurysm (AAA) were reviewed. Starting from October 2015, 83 patients (treatment group) underwent NBCA injection into the aneurysmal sac during EVAR. The incidence of T2E at 7 days and AAA sac diameter 12 months after EVAR were compared with those of the control group comprising 93 consecutive patients who underwent EVAR alone before 2015. The incidence of T2E at 7 days was significantly lower in the treatment group (2.4%) than in the control group (22.6%) (P < 0.001). AAA sac diameter at 12 months in the treatment group had a mean decrease of 6.6 mm as compared with the mean 4.4 mm in the control group (P = 0.026). In multivariate analysis, NBCA injection was significantly related to the reduction of incidence of T2E at 7 days (odds ratio = 11.8, P < 0.001) and a decrease in AAA sac diameter at 12 months (P < 0.001). There was no NBCA injection-related complication and reintervention in the treatment group.

CONCLUSIONS

NBCA injection might be safe and useful to reduce the incidence of T2Es and to prevent AAA sac expansion.

Aortic sac enlargement after endovascular aneurysm repair: volume-related changes and the impact of intraluminal thrombus

Purpose

Abdominal aortic aneurysm (AAA) growth after endovascular aneurysm repair (EVAR) is still unpredictable. The issue of optimal frequency of computed tomography angiography for surveillance and its measurement method accuracy remain unclear. We aimed to assess the value of abdominal aneurysm sac volume measurement for detecting expansions and the association of preprocedural intraluminal thrombus (ILT) volume with aneurysm sac growth following EVAR.

Material and methods

A total of 107 patients underwent elective EVAR. Inclusion criteria provided a cohort of 39 patients. Changes of postoperative maximum aneurysm sac diameter and AAA volume were calculated. Volumetric AAA changes and demographic data of the cases with clinically irrelevant AAA diameter enlargement were evaluated. Preoperative ILT volumes were collected. ILT and AAA sac volume ratio was calculated. Statistical data analysis was performed using standard methods.

Results

The mean changes of maximum AAA diameter and volume in percentage after EVAR were –5.08 ± 8.20 mm and –13.39 ± 23.32%, respectively. A moderate positive linear correlation between those changes was found (R² = 0.731; p < 0.0001). The mean relative AAA volume increase in cases without clinically relevant diameter enlargement was 11.50 ± 8.27%. The means of ILT and AAA sac ratios were 0.59 ± 0.17 and 0.52 ± 1.8 in growing AAA sac and in stable or shrinking AAA sac groups, respectively (p = 0.308).

Conclusions

Volumetric AAA measurement may be useful as an additional method to diameter measurement after EVAR to identify clinically relevant sac growth. Preoperative volume of ILT may not significantly affect the growth rate of AAA after EVAR.

Aortic Banding to Treat Simultaneously a Type Ia Endoleak and Aortic Neck Rupture during Endovascular Abdominal Aortic Aneurysm Repair

BACKGROUND

Type Ia endoleak due to inadequate seal at the proximal end of the endograft is not infrequent during the initial operation. However, repeated attempts at balloon inflation or over-dilatation of the balloon can produce high axial pressures and can lead to aortic neck rupture with hemodynamic instability.

METHODS

The purpose of the paper is to present a useful technique for simultaneously treating a type Ia endoleak and aortic neck rupture during endovascular abdominal aortic aneurysm repair.

RESULTS

The technique for treating a type Ia endoleak has been described, but it was used for the first time to treat simultaneously a type Ia endoleak and rupture of the aortic neck with active bleeding during endovascular abdominal aortic aneurysm repair. After laparotomy, the left renal vein was ligated and a proximal control was achieved with placement of a vascular clamp above the renal arteries. Effective external banding of the infrarenal neck was performed with two 10-mm polyester Dacron limbs tied in the same fashion, close to one another, and parallel just below the renal arteries. We describe the steps of the surgical technique in detail and we analyze crucial issues associated with the technique.

CONCLUSIONS

In this paper, we presented a useful technique for simultaneously treating a type Ia endoleak and aortic neck rupture during endovascular abdominal aortic aneurysm repair. Effective external banding of the infrarenal neck led to control of the hemorrhage and exclusion of the blood flow in the aneurysm sac.

Stent-graft surface movement after endovascular aneurysm repair: baseline parameters for prediction, and association with migration and stent-graft-related endoleaks

OBJECTIVES

To evaluate the influence of baseline parameters on the occurrence of stent-graft surface movement after endovascular aneurysm repair (EVAR) and to investigate its association with migration and stent-graft-related endoleaks (srEL).

METHODS

In this retrospective, cross-sectional study, three-dimensional surface models of the stent-graft, delimited by landmarks using custom-built software, were derived from the pre-discharge and last follow-up computed tomography angiography (CTA). Stent-graft surface movement in the proximal anchoring zone between these examinations was considered significant at a threshold of 9 mm. The Cox proportional hazards model was used to determine baseline variables associated with the occurrence of stent-graft surface movement. The association between migration and srEL with stent-graft surface movement was tested with the chi-square and the Fisher exact test, respectively.

RESULTS

Stent-graft surface movement was observed in 54 (28.9%) of 187 patients. Multivariate analysis revealed that age ([HR] 1.05; p = 0.017), proximal neck diameter ([HR] 5.07; p < 0.001), infrarenal aortic neck angulation ([HR] 1.02, p = 0.002), and proximal neck length ([HR] 0.62, p < 0.001) were significantly associated with the occurrence of stent-graft surface movement. Migration and srEL occurred in 17 (31.5%) and 5 (9.3%) patients, with and 11 (8.3%) and 2 (1.5%) without stent-graft surface movement (p < 0.001, p = 0.022).

CONCLUSIONS

Age, neck diameter, infrarenal neck angulation, and proximal neck length were significantly associated with the occurrence of stent-graft surface movement. Apart from possible use of adjunctive sealing systems, concerned patients may benefit from regular CTA surveillance, enabling timely diagnosis of subtle changes of stent-graft position.

KEY POINTS

• Stent-graft surface movement, demonstrating subtle, three-dimensional changes in stent-graft position in the proximal anchoring zone, can be derived from CTA examinations. • Age, proximal neck diameter, and infrarenal neck angulation were significantly associated with an increased incidence of stent-graft surface movement. Stent-graft surface movement is significantly more frequent in patients with stent-graft migration and stent-graft-related endoleaks. • Consideration of risk factors for stent-graft surface movement may help to identify patients who might benefit from regular CTA surveillance and timely diagnosis of subtle changes of stent-graft position, enabling re-interventions to prevent migration and srEL.

Application of Baseline Clinical and Morphological Parameters for Prediction of Late Stent Graft Related Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysm

OBJECTIVES

To evaluate the influence of baseline clinical and morphological parameters on the occurrence of a late stent graft related endoleak (srEL; types 1 and 3) after endovascular aneurysm repair (EVAR).

METHODS

This is a retrospective case control study of patients who were routinely followed up after EVAR of abdominal aortic aneurysms. Pre-interventional, pre-discharge, and last available multislice computed tomography angiogram (MSCTA) of 279 patients were analysed. Stent graft related endoleaks detected by follow up MSCTA at least six months after EVAR were specified as late srEL. Baseline demographic characteristics and morphological variables were derived from the pre-interventional and pre-discharge MSCTA. Univariable and multivariable analysis with a Cox proportional hazards model were used to determine baseline factors associated with the occurrence of a late srEL.

RESULTS

Twenty-four (8.6%) of 279 patients suffered a late srEL, during a mean MSCTA follow up of 30.9 ± 25.8 (23.5, IQR 10.6-42.8) months. In the univariable analysis, age (hazard ratio [HR] 1.09; p = .001), female sex (HR 3.25; p = .014), right iliac sealing diameter (HR 10.04; p = .03), left iliac sealing diameter (HR 8.65; p = .001), infrarenal aortic neck angulation (HR 1.02; p = .011), and suprarenal fixation level (HR 3.47; p = .014) were significantly associated with an increased incidence of late srEL. Age (HR 1.08; p = .012), female sex (HR 2.72; p = .049), and left iliac sealing diameter (HR 4.48; p = .033) proved to be risk factors significantly associated with a higher incidence of late srEL in multivariable analysis.

CONCLUSIONS

Older patients, those with female gender, and those with larger left iliac sealing diameters seem to experience higher rates of late srEL. Independent confirmation of these must be addressed in larger studies.

Positron Emission Tomography/Computed Tomography Predicts and Detects Complications After Endovascular Repair of Abdominal Aortic Aneurysms

Purpose: To assess if aortic 18F-fluorodeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT) could play a role in predicting complications after endovascular aneurysm repair (EVAR). Materials and Methods: This study involved 2 cohorts of men with abdominal aortic aneurysm treated by EVAR: those who underwent a PET/CT scan before EVAR (n=17) and those who had a PET/CT during follow-up (n=34). Uptake of FDG was measured as the standardized uptake value (SUV). D-dimer, a marker of fibrinolysis, was measured in blood drawn concomitantly with the PET/CT. Results: A significant uptake of FDG in the aneurysm wall was detected by PET/CT before EVAR in 6 of 17 patients. During the first year after EVAR, type II endoleaks developed in 5 of these FDG+ patients vs 3 of 11 FDG- patients (p=0.04). Two of the FDG+ patients had continued sac growth and required conversion to open repair. A significant association between sac growth rate, SUV, and the presence of endoleak was found in the 34 patients who underwent PET/CT after EVAR. Finally, D-dimer was significantly increased in patients with both endoleak and positive PET/CT in the post-EVAR group. Conclusion: This study suggests that the presence of FDG uptake in the aortic wall might be a useful tool to predict patients at high risk of developing post-EVAR complications.

Contrast-enhanced ultrasound and/or colour duplex ultrasound for surveillance after endovascular abdominal aortic aneurysm repair: a systematic review and economic evaluation

BACKGROUND

Endovascular abdominal aortic aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) is less invasive than open surgery, but may be associated with important complications. Patients receiving EVAR require long-term surveillance to detect abnormalities and direct treatments. Computed tomography angiography (CTA) has been the most common imaging modality adopted for EVAR surveillance, but it is associated with repeated radiation exposure and the risk of contrast-related nephropathy. Colour duplex ultrasound (CDU) and, more recently, contrast-enhanced ultrasound (CEU) have been suggested as possible, safer, alternatives to CTA.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of imaging strategies, using either CDU or CEU alone or in conjunction with plain radiography, compared with CTA for EVAR surveillance.

DATA SOURCES

Major electronic databases were searched, including MEDLINE, EMBASE, Science Citation Index, Scopus' Articles-in-Press, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE) and NHS Economic Evaluation Database from 1996 onwards. We also searched for relevant ongoing studies and conference proceedings. The final searches were undertaken in September 2016.

METHODS

We conducted a systematic review of randomised controlled trials and cohort studies of patients with AAAs who were receiving surveillance using CTA, CDU and CEU with or without plain radiography. Three reviewers were involved in the study selection, data extraction and risk-of-bias assessment. We developed a Markov model based on five surveillance strategies: (1) annual CTA; (2) annual CDU; (3) annual CEU; (4) CDU together with CTA at 1 year, followed by CDU on an annual basis; and (5) CEU together with CTA at 1 year, followed by CEU on an annual basis. All of these strategies also considered plain radiography on an annual basis.

RESULTS

We identified two non-randomised comparative studies and 25 cohort studies of interventions, and nine systematic reviews of diagnostic accuracy. Overall, the proportion of patients who required reintervention ranged from 1.1% (mean follow-up of 24 months) to 23.8% (mean follow-up of 32 months). Reintervention was mainly required for patients with thrombosis and types I-III endoleaks. All-cause mortality ranged from 2.7% (mean follow-up of 24 months) to 42% (mean follow-up of 54.8 months). Aneurysm-related mortality occurred in < 1% of the participants. Strategies based on early and mid-term CTA and/or CDU and long-term CDU surveillance were broadly comparable with those based on a combination of CTA and CDU throughout the follow-up period in terms of clinical complications, reinterventions and mortality. The economic evaluation showed that a CDU-based strategy generated lower expected costs and higher quality-adjusted life-year (QALYs) than a CTA-based strategy and has a 63% probability of being cost-effective at a £30,000 willingness-to-pay-per-QALY threshold. A CEU-based strategy generated more QALYs, but at higher costs, and became cost-effective only for high-risk patient groups.

LIMITATIONS

Most studies were rated as being at a high or moderate risk of bias. No studies compared CDU with CEU. Substantial clinical heterogeneity precluded a formal synthesis of results. The economic model was hindered by a lack of suitable data.

CONCLUSIONS

Current surveillance practice is very heterogeneous. CDU may be a safe and cost-effective alternative to CTA, with CTA being reserved for abnormal/inconclusive CDU cases.

FUTURE WORK

Research is needed to validate the safety of modified, more-targeted surveillance protocols based on the use of CDU and CEU. The role of radiography for surveillance after EVAR requires clarification.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016036475.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Rescue of proximal failure of endovascular abdominal aortic aneurysm repair with standard and fenestrated grafts

BACKGROUND

This study aimed to assess the outcomes of standard and fenestrated grafts to treat proximal failure of previous endovascular aneurysm repair (EVAR) in a tertiary referral center.

METHODS

All patients undergoing elective implantation of a standard or fenestrated graft after proximal failure of a previous EVAR between April 2010-November 2018 were included. Data were collected prospectively.

RESULTS

Fifty procedures were performed in 49 patients (45 male; mean age 74.6±7 years). A fenestrated proximal cuff was used in 24 (48%) cases, a composite bifurcated configuration in 21 (42%) cases, and EVAR in 5 (10%) cases. Technical success was achieved in all 5 EVAR cases and 41 of 45 FEVAR cases (91.1%). Iliac artery access problems due to the presence of the previous graft were encountered in eight (16%) procedures and renal artery catheterization difficulties in grafts with suprarenal fixation in seven (15.6%) procedures. There was one (2%) early death due to retroperitoneal bleeding. Early major complications occurred in three (6%) patients. Median follow-up was 26 months (range 1-77). Late occlusion occurred in two (1.3%) of the 151 targeted vessels. One patient needed permanent dialysis. Nine patients died during follow-up, one (2%) of them aneurysm-related. Ten (20.4%) patients presented with major complications during follow-up of which nine (18.4%) needed reintervention. Estimated freedom from reintervention at 1 and 3 years was 89.3±5.1% and 78.8±7.3%, respectively.

CONCLUSIONS

Repair with fenestrated grafts represents a safe and effective treatment option. Increased technical challenges are to be expected due to the previous graft.

Outcomes of endovascular treatment of endoleak type Ia after EVAR: a systematic review of the literature

INTRODUCTION

Endovascular repair of infra-renal aortic aneurysm (EVAR) has become treatment of choice. However, individuals undergoing EVAR have a high re-intervention rate. The aim of this study is to evaluate the current endovascular treatment modalities of endoleak type Ia (ET Ia) treatment after EVAR and their outcome.

EVIDENCE ACQUISITION

A systematic review and meta-analysis was performed. MEDLINE, EMBASE and Cochrane databases were searched with PRISMA methodology for studies reporting on endovascular treatment of ET Ia after EVAR. Studies presenting treatment of intra-operative ET Ia were excluded.

EVIDENCE SYNTHESIS

Two international registries, fourteen non-randomized retrospective and twelve case-report studies were included reporting on 356 patients. Reported endovascular techniques included fenestrated-, branched-, chimney EVAR, endovascular sealing (EVAS), endoanchors, embolization techniques, cuff and/or "giant" Palmaz stents. Technical success rate ranged from 90% to 100%, with intra-operative mortality rate of 0%. During early period, persistence of ET Ia was 3.4% (9/262) and the re-intervention rate was 3.5% (8/227). The 30-day mortality rate was 2% (7/356). Mean follow-up was 22.4 months±18. Presence of ET Ia was 5.9% (21/356), and the reintervention rate was 5.1% (18/349). The mortality rate was 13% (26/203), while the primary patency rate of TVs ranged from 94.3% to 100%.

CONCLUSIONS

A multitude of techniques for endovascular repair for ET Ia exists. No strong evidence supports one specific technique. The early and mid-term outcomes are encouraging in terms of ET Ia resolution, mortality and morbidity rates.