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Spath P, Campana F, Gallitto E, Pini R, Mascoli C, Sufali G, Caputo S, Sonetto A, Faggioli G, Gargiulo M. Impact of iliac access in elective and non-elective endovascular repair of abdominal aortic aneurysm. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:85-98. [PMID: 38635284 DOI: 10.23736/s0021-9509.24.12987-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Endovascular aortic repair (EVAR) is nowadays the establishment treatment for patients with abdominal aortic aneurysm (AAA) both in elective and urgent setting. Despite the large applicability and satisfactory results, the presence of hostile iliac anatomy affects both technical and clinical success. This narrative review aimed to report the impact of iliac access and related adjunctive procedures in patients undergoing EVAR in elective and non-elective setting. Hostile iliac access can be defined in presence of narrowed, tortuous, calcified, or occluded iliac arteries. These iliac characteristics can be graded by the anatomic severity grade score to quantitatively assess anatomic complexity before undergoing treatment. Literature shows that iliac hostility has an impact on device navigability, insertion and perioperative and postoperative results. Overall, it has been correlated to higher rate of access issues, representing up to 30% of the first published EVAR experience. Recent innovations with low-profile endografts have reduced large-bore sheaths related issues. However, iliac-related complications still represent an issue, and several adjunctive endovascular and surgical strategies are nowadays available to overcome these complications during EVAR. In urgent settings iliac hostility can significantly impact on particular time sensitive procedures. Moreover, in case of severe hostility patients might be written off for EVAR repair might be inapplicable, exposing to higher mortality/morbidity risk in this urgent/emergent setting. In conclusion, an accurate anatomical evaluation of iliac arteries during preoperative planning, materials availability, and skilled preparation to face iliac-related issues are crucial to address these challenges.
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Affiliation(s)
- Paolo Spath
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy -
- Unit of Vascular Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy -
| | - Federica Campana
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Enrico Gallitto
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Vascular Surgery, IRCCS University Hospital S. Orsola, Bologna, Italy
| | - Rodolfo Pini
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Vascular Surgery, IRCCS University Hospital S. Orsola, Bologna, Italy
| | - Chiara Mascoli
- Unit of Vascular Surgery, IRCCS University Hospital S. Orsola, Bologna, Italy
| | - Gemmi Sufali
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Stefania Caputo
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alessia Sonetto
- Unit of Vascular Surgery, IRCCS University Hospital S. Orsola, Bologna, Italy
| | - Gianluca Faggioli
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Vascular Surgery, IRCCS University Hospital S. Orsola, Bologna, Italy
| | - Mauro Gargiulo
- Unit of Vascular Surgery, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Vascular Surgery, IRCCS University Hospital S. Orsola, Bologna, Italy
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Thirty-day Results from the ZEPHYR Registry: Outcomes of EVAR Using the Zenith Alpha™ Abdominal Endovascular Graft for the Treatment of AAA in 347 Patients. Ann Vasc Surg 2021; 78:170-179. [PMID: 34474131 DOI: 10.1016/j.avsg.2021.06.020] [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: 05/01/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND To report technical and clinical 30-day results following treatment with the Zenith Alpha™ abdominal stent graft from the ZEnith alPHa for aneurYsm Repair Registry (ZEPHYR). METHODS Multicenter, nonrandomized, single arm, core laboratory-controlled, prospective registry collecting data on the Zenith Alpha Abdominal Endovascular Graft being used in subjects with abdominal aortic aneurysms (AAA) from sites in Germany, Belgium, and The Netherlands between December 2016 and December 2019. Inclusion criteria were non-ruptured AAAs with a maximum diameter ≥50 mm or enlargement >5 mm over 6 months with an AAA neck length ≥10 mm (site reported). Primary outcome measure was treatment success at 30 days. Treatment success was defined as a combined endpoint consisting of technical and clinical success. Technical success was defined as successful stent graft delivery and deployment as well as successful removal of the delivery system. Clinical success at 30 days was defined as freedom from type I and III endoleak, aneurysm rupture, conversion to open surgery and stent graft occlusion. RESULTS Three hundred forty-seven subjects were included from 14 sites with a median age of 73.0 years (IQR 68.0-79.0). Thirty-four patients were female (9.8%). The median AAA diameter was 58.3 mm (IQR 55.0-63.5). The median proximal neck diameter was 23.6 mm (IQR 22.0-25.2) with a median proximal neck length of 24.4 mm (IQR 15.0-34.8) and a median infrarenal neck angulation of 24.5° (IQR 15.0-35.0). The right and left common iliac diameter were 16.1 mm (IQR 14.1-19.4) and 16.2 mm (IQR 14.1-19.1), respectively. The treatment success rate at 30 days was 94.8% (N = 329). Technical success was achieved in 333 patients (96.0%). The clinical success rate at 30 days was 98.8% (N = 343). Three patients had limb occlusions at 30 day follow up (0.9%). One patient had a type Ib endoleak (0.3%). Seventy percent of vascular access approaches were percutaneous. The reintervention rate was 1.7% (N = 6) within 30 days. Indications for reinterventions were a false aneurysm at puncture site (N = 1), limb complications (N = 2), stentgraft-associated renal artery occlusions (N = 2), and an external iliac artery thrombosis (N = 1). CONCLUSIONS Endovascular aneurysm repair using the Zenith Alpha Abdominal Endovascular Graft is effective in the short term. Long term results will be reported in the future.
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Fujimura N, Imazuru T, Matsumura H, Shibata T, Furuyama T, Kaneko K, Uchiyama H, Morikage N, Uchida T, Teshima E, Yamaoka T, Masuhara H, Ueda H, Arakawa M, Norimatsu T, Obara H, Onitsuka S. Two-Year Results of a Multicenter Prospective Observational Study of the Zenith Spiral-Z Limb Deployed in the External Iliac Artery During Endovascular Aneurysm Repair. Circ J 2020; 84:1764-1770. [DOI: 10.1253/circj.cj-20-0195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Naoki Fujimura
- Division of Vascular Surgery, Saiseikai Central Hospital
| | - Tomohiro Imazuru
- Department of Cardiovascular Surgery, Teikyo University Hospital
| | - Hitoshi Matsumura
- Department of Cardiovascular Surgery, Fukuoka University School of Medicine
| | - Tsuyoshi Shibata
- Department of Cardiovascular Surgery, Hakodate Municipal Hospital
| | - Tadashi Furuyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University
| | - Kenjiro Kaneko
- Department of Vascular Surgery, Shin-yurigaoka General Hospital
| | | | | | | | - Eiichi Teshima
- Department of Cardiovascular Surgery, Fukuoka Wajiro Hospital
| | | | - Hiroshi Masuhara
- Department of Cardiovascular Surgery, Toho University Omori Medical Center
| | - Hideki Ueda
- Department of Cardiovascular Surgery, Chiba University
| | - Mamoru Arakawa
- Department of Cardiovascular Surgery, Nerima Mitsugaoka Hospital
| | - Togo Norimatsu
- Department of Vascular Surgery, Sakakibara Memorial Hospital
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine
| | - Seiji Onitsuka
- Department of Surgery, Kurume University School of Medicine
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Lindsay T, Jazaeri O, Sherman SM, Saunders AT, Forbes TL, Lindsay T, Nelson W, Harlock J, Feezor R, Stone P, Jazaeri O, Akers D, Forbes T, Singh M, Fernandez J, Kougias P, Laskowski I, Hurie J, Lee CJ, Jain A, Papenhausen M, Oskin T, Simonian G, Mueller M, Parvanthaneni S, Tamaddon H, Bruen K, Rahini S, Mehta M, Nagpal S, Patel A, Kulwicki A, Ellozy S. Final results from a postmarket registry of an iliac leg graft with a continuous, spiral nitinol stent. J Vasc Surg 2020; 72:576-583.e1. [DOI: 10.1016/j.jvs.2019.10.078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
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Abdulrasak M, Sonesson B, Singh B, Resch T, Dias NV. Long-term outcomes of infrarenal endovascular aneurysm repair with a commercially available stent graft. J Vasc Surg 2020; 72:520-530.e1. [DOI: 10.1016/j.jvs.2019.09.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 09/29/2019] [Indexed: 12/21/2022]
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Coelho A, Nogueira C, Lobo M, Gouveia R, Campos J, Augusto R, Coelho N, Semião AC, Ribeiro JP, Canedo A. Impact of Post-EVAR Graft Limb Kinking in EVAR Limb Occlusion: Aetiology, Early Diagnosis, and Management. Eur J Vasc Endovasc Surg 2019; 58:681-689. [DOI: 10.1016/j.ejvs.2019.03.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 03/10/2019] [Accepted: 03/11/2019] [Indexed: 12/26/2022]
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Abstract
CLINICAL/METHODICAL ISSUE New technical developments in endovascular aortic repair (EVAR) have broadened the range of patients eligible for minimally invasive aneurysm treatment. Optimization of delivery sheaths and catheters by considerable downsizing of diameters, increase of pushability and stability combined with flexibility are important parameters. PERFORMANCE Especially patients characterized by small and tortuous iliac access vessels can nowadays be treated by EVAR. Ease and effectiveness of applicability guarantee safety and quality improvement, which results in better treatment of patients. Progress in stent-graft design with integrated options for repositioning, active positioning and aneurysm sealing facilitate treatment of angulated vessel segments or hitherto unsuitable sealing zones. PRACTICAL RECOMMENDATIONS Interventionalists have to be familiar with all available stent-graft materials and techniques. Profound knowledge helps to choose the best material for a patient's individual anatomy, confident application and long-term satisfactory results.
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Sirignano P, Capoccia L, Pranteda C, Montelione N, Mansour W, d’Adamo A, Formiconi M, Speziale F. Aortic Bifurcation Morphology Alone is Not Able to Predict Outcome in Patients Submitted to Elective Endovascular Abdominal Aortic Aneurysm Repair. Cardiovasc Intervent Radiol 2017; 41:218-224. [DOI: 10.1007/s00270-017-1831-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 10/25/2017] [Indexed: 12/01/2022]
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Smeds MR, Charlton-Ouw KM. Infrarenal endovascular aneurysm repair: New developments and decision making in 2016. Semin Vasc Surg 2016; 29:27-34. [PMID: 27823586 DOI: 10.1053/j.semvascsurg.2016.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
New developments in infrarenal abdominal aortic aneurysm stent-graft devices have made more patients eligible for endovascular aneurysm repair (EVAR). Recent US Food and Drug Administration approval for fenestrated endograft repair and impending approval for iliac branch devices extend the proximal and distal landing zones. Better deployment systems allow for partial deployment of endografts to facilitate repositioning, and more flexible designs allow for treatment of angulated infrarenal aneurysm necks and tortuous iliac arteries. New iterations of endografts have smaller delivery catheter diameters, which facilitate traversal of smaller access vessels. Long-term outcomes data are still accumulating and it remains to be seen whether EVAR for this expanded-indication abdominal aortic aneurysms anatomy has the same durability as standard EVAR. More options for repair also mean vascular surgeons must select the best EVAR device based on each patient's abdominal aortic aneurysm anatomy.
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Affiliation(s)
- Matthew R Smeds
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Arkansas for Medical Sciences, 4301 West Markham Street #520-2, Little Rock, AR 72205-7199.
| | - Kristofer M Charlton-Ouw
- Division of Vascular and Endovascular Surgery, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), TX
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Sobocinski J, Briffa F, Holt PJ, Martin Gonzalez T, Spear R, Azzaoui R, Maurel B, Haulon S. Evaluation of the Zenith low-profile abdominal aortic aneurysm stent graft. J Vasc Surg 2015; 62:841-7. [PMID: 26243207 DOI: 10.1016/j.jvs.2015.04.452] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Low-profile (LP) stent grafts are now commercially available in Europe for endovascular aortic aneurysm repair (EVAR). In this study the midterm outcomes and characteristics of patients treated with this last generation of stent grafts were compared with a cohort of patients treated with "standard-profile" (SP) stent grafts. METHODS The current study enrolled all patients treated for elective EVAR by the SP Zenith Flex stent graft (Cook Medical, Bloomington, Ind) between March 2010 and November 2011 and patients treated for elective EVAR by the Zenith LP stent graft (Cook Medical) between November 2011 and March 2013. All patients had a follow-up >18 months. Preoperative computed tomography angiograms were analyzed on a dedicated three-dimensional workstation. All data were prospectively collected in an electronic database and retrospectively analyzed. A comparative study was conducted. RESULTS The present study included 208 patients (107 SP and 101 LP). Patients' physiologic characteristics were similar in both groups. The iliac anatomy was considered "more challenging" in LP patients: respectively, 7% and 22% (P = .002) of SP and LP patients had bilateral external iliac diameter <7 mm; and 16% and 34% (P = .005) had a combination of an external iliac diameter <7 mm and an iliac tortuosity ratio index >1.5. No 30-day deaths were documented. The 24-month freedom from reintervention and overall survival rates after SP and LP were, respectively, 88% and 91% (P = .450) and 92% and 96% (P = .153). The 24-month rates for freedom from sac expansion and from limb occlusion were 96.4% and 98.7% (P = .320) and 92% and 95% (P = .293), respectively. One patient in each group presented with a type I endoleak during follow-up, and two LP patients presented with a type III endoleak (P = .235). CONCLUSIONS This study demonstrates that the last-generation LP stent grafts have favorable midterm outcomes similar to SP stent grafts despite being used to treat more patients with unfavorable iliac anatomy.
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Affiliation(s)
- Jonathan Sobocinski
- Aortic Centre, Vascular Surgery, Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, Lille, France.
| | - Florent Briffa
- Aortic Centre, Vascular Surgery, Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Peter J Holt
- St George's Vascular Institute, University of London, London, United Kingdom
| | - Teresa Martin Gonzalez
- Aortic Centre, Vascular Surgery, Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Rafaëlle Spear
- Aortic Centre, Vascular Surgery, Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Richard Azzaoui
- Aortic Centre, Vascular Surgery, Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Blandine Maurel
- Aortic Centre, Vascular Surgery, Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Stéphan Haulon
- Aortic Centre, Vascular Surgery, Hôpital Cardiologique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
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Stather PW, Rhema IA, Sidloff DA, Sayers RD, Bown MJ, Choke E. Short-Term Outcomes of Management of Endovascular Aneurysm Repair in Patients With Dilated Iliacs. Vasc Endovascular Surg 2015; 49:75-8. [PMID: 26145754 DOI: 10.1177/1538574415593761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study aims to evaluate outcomes following endovascular aneurysm repair (EVAR) in patients with dilated but not aneurysmal common iliac arteries. METHODS Data prospectively collected from 342 elective EVARs were analyzed retrospectively. Dilated common iliac anatomy was defined as 21 to 24 mm. Patients with iliac aneurysms or external iliac artery (EIA) extension were excluded. Patients were followed up using clinical review, plain radiographs, duplex imaging, and selective computed tomography scanning. RESULTS Median age was 75 years with a mean follow-up of 3.6 years. In all, 33 patients had dilated common iliac arteries (DCIAs) and 309 had non-dilated common iliac arteries (NDCIA). There was no difference in aneurysm diameter or neck characteristics (length, diameter, angulation, thrombus, and flare) between the subgroups. There was no significant difference in technical success, 30-day mortality, late mortality, aneurysm-related mortality, 30-day reinterventions, stent graft migration, limb occlusion, sac expansion, graft rupture, type 1 endoleaks, type 3 endoleaks, and total reinterventions (all Ps > .05). There was a significant decrease in type II endoleaks in patients with DCIA compared to NDCIA (NDCIA 12.9% and DCIA 0.0%; P = .02). CONCLUSION Patients presenting with abdominal aortic aneurysms with DCIA can be successfully treated with EVAR with no increase in complications without extension into the EIA.
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Affiliation(s)
- P W Stather
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - I A Rhema
- Leicester Medical School, University of Leicester, Leicester, United Kingdom
| | - D A Sidloff
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - R D Sayers
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - M J Bown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom NIHR Biomedical Research Unit, University of Leicester, Leicester, United Kingdom
| | - E Choke
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
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Thromboembolic Complications after Zenith® Low Profile Endovascular Graft for Infrarenal Abdominal Aneurysms. Cardiovasc Intervent Radiol 2014; 38:600-5. [DOI: 10.1007/s00270-014-0972-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 06/09/2014] [Indexed: 01/20/2023]
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Commentary on 'An optimal combination for EVAR: low profile endograft body and continuous spiral stent limbs'. Eur J Vasc Endovasc Surg 2013; 46:34-5. [PMID: 23643414 DOI: 10.1016/j.ejvs.2013.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 04/02/2013] [Indexed: 11/22/2022]
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