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Domanin M, Piazzoli G, Trimarchi S, Vergara C. Image-Based Displacements Analysis and Computational Blood Dynamics after Endovascular Aneurysm Repair. Ann Vasc Surg 2020; 69:400-412. [PMID: 32738387 DOI: 10.1016/j.avsg.2020.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND To examine intraheartbeat displacements (IHD) and geometrical changes of endografts for abdominal aortic aneurysm repair over the course of years, defined as follow-up displacements (FUD), and to correlate them with computational fluid dynamics (CFD). Despite the widespread use of endovascular aneurysm repair (EVAR), we still know little about endograft behavior after deployment. METHODS Two cases, treated with either expanded polytetrafluoroethylene on a nitinol stent frame (PI) or with woven polyester fabric sutured to a stainless-steel Z stent skeleton (PII), were submitted to dynamic computed tomography angiography at 1, 12, and 60 months after implantation. After segmentation, IHD were computed as displacements of the reconstructed surface with respect to the diastolic instant. Similarly, FUD were studied using imaging techniques that align temporal successive segmentations. In addition, numerical simulations for blood dynamics were performed to compute viscous forces, specifically wall shear stress and time-averaged wall shear stress (TAWSS). RESULTS IHD analysis showed slight translations without deformation for the PI endograft with respect to the stiffer stainless-steel endograft behavior of PII. FUD showed in PI motion of the metallic struts mainly focused on the distal main body of the endograft and in the zone overlapping with iliac branches. In PII, we observed a huge FUD in the middle and inferior-anterior regions of the main body. CFD analysis revealed changes of velocity patterns associated with remodeling of the iliac zone for PI and of the main body region for PII, where flow impinges the lumen wall and progressively induces deformation of the endograft wires. Measurement of TAWSS demonstrated flow disturbances in the enlarged region correlated with displacement analysis. CONCLUSIONS Image-based displacement analysis associated with CFD enabled very subtle evaluations of endograft behavior on different temporal scales. This kind of study could be helpful both for physicians, forecasting evolution during the life span of the endograft, and manufacturers, giving them useful information about endograft implant performance and design.
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Affiliation(s)
- Maurizio Domanin
- Department of Clinical Sciences and Community Health, Università di Milano, Milan, Italy; Unità Operativa di Chirurgia Vascolare, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy.
| | - Giulia Piazzoli
- MOX, Dipartimento di Matematica, Politecnico di Milano, Milan, Italy
| | - Santi Trimarchi
- Department of Clinical Sciences and Community Health, Università di Milano, Milan, Italy; Unità Operativa di Chirurgia Vascolare, Fondazione I.R.C.C.S. Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Christian Vergara
- LABS, Dipartimento di Chimica, Materiali e Ingegneria Chimica, Politecnico di Milano, Milan, Italy
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Asenbaum U, Schoder M, Schwartz E, Langs G, Baltzer P, Wolf F, Prusa AM, Loewe C, Nolz R. Stent-graft surface movement after endovascular aneurysm repair: baseline parameters for prediction, and association with migration and stent-graft-related endoleaks. Eur Radiol 2019; 29:6385-6395. [PMID: 31250169 PMCID: PMC6828830 DOI: 10.1007/s00330-019-06282-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/25/2019] [Accepted: 05/22/2019] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Ulrika Asenbaum
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna - Vienna General Hospital, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Maria Schoder
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna - Vienna General Hospital, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Ernst Schwartz
- Computational and Imaging Research Laboratory, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Georg Langs
- Computational and Imaging Research Laboratory, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Pascal Baltzer
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna - Vienna General Hospital, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Florian Wolf
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna - Vienna General Hospital, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Alexander M Prusa
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna - Vienna General Hospital, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Richard Nolz
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna - Vienna General Hospital, Waehringer Guertel 18-20, A-1090, Vienna, Austria.
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Nolz R, Schoder M, Baltzer P, Prusa A, Javor D, Loewe C, Asenbaum U. Application of Baseline Clinical and Morphological Parameters for Prediction of Late Stent Graft Related Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg 2019; 58:24-32. [PMID: 31160189 DOI: 10.1016/j.ejvs.2018.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 11/05/2018] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Richard Nolz
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria
| | - Maria Schoder
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria
| | - Pascal Baltzer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria
| | - Alexander Prusa
- Department of Vascular Surgery, Medical University of Vienna, Austria
| | - Domagoj Javor
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria
| | - Christian Loewe
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria
| | - Ulrika Asenbaum
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Austria.
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Prevalence and risk factors of type II endoleaks after endovascular aneurysm repair: A meta-analysis. PLoS One 2017; 12:e0170600. [PMID: 28182753 PMCID: PMC5300210 DOI: 10.1371/journal.pone.0170600] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 01/07/2017] [Indexed: 02/05/2023] Open
Abstract
Objectives This systematic review and meta-analysis aims to determine the current evidence on risk factors for type II endoleaks after endovascular aneurysm repair (EVAR). Materials and methods A systematic literature search was carried out for studies that evaluated the association of demographic, co-morbidity, and other patient-determined factors with the onset of type II endoleaks. Pooled prevalence of type II endoleaks after EVAR was updated. Results Among the 504 studies screened, 45 studies with a total of 36,588 participants were included in this review. The pooled prevalence of type II endoleaks after EVAR was 22% [95% confidence interval (CI), 19%–25%]. The main factors consistently associated with type II endoleaks included age [pooled odds ratio (OR), 0.37; 95% CI, 0.31–0.43; P<0.001], smoking (pooled OR, 0.71; 95% CI, 0.55–0.92; P<0.001), patent inferior mesenteric artery (pooled OR, 1.98; 95% CI, 1.06–3.71; P = 0.012), maximum aneurysm diameter (pooled OR, 0.23; 95% CI, 0.17–0.30; P<0.001), and number of patent lumbar arteries (pooled OR, 3.07; 95% CI, 2.81–3.33; P<0.001). Sex, diabetes, hypertension, anticoagulants, antiplatelet, hyperlipidemia, chronic renal insufficiency, types of graft material, and chronic obstructive pulmonary diseases (COPD) did not show any association with the onset of type II endoleaks. Conclusions Clinicians can use the identified risk factors to detect and manage patients at risk of developing type II endoleaks after EVAR. However, further studies are needed to analyze a number of potential risk factors.
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de Vries JPPM, Vos JA. Commentary on 'Selective AAA sac Embolization During EVAR to Prevent Type II Endoleaks'. Eur J Vasc Endovasc Surg 2016; 51:640. [PMID: 26952344 DOI: 10.1016/j.ejvs.2016.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 01/24/2016] [Indexed: 11/19/2022]
Affiliation(s)
- J P P M de Vries
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - J A Vos
- Department of Interventional Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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Brown A, Saggu GK, Bown MJ, Sayers RD, Sidloff DA. Type II endoleaks: challenges and solutions. Vasc Health Risk Manag 2016; 12:53-63. [PMID: 27042087 PMCID: PMC4780400 DOI: 10.2147/vhrm.s81275] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Type II endoleaks are the most common endovascular complications of endovascular abdominal aortic aneurysm repair (EVAR); however, there has been a divided opinion regarding their significance in EVAR. Some advocate a conservative approach unless there is clear evidence of sac expansion, while others maintain early intervention is best to prevent adverse late outcomes such as rupture. There is a lack of level-one evidence in this challenging group of patients, and due to a low event rate of complications, large numbers of patients would be required in well-designed trials to fully understand the natural history of type II endoleak. This review will discuss the imaging, management, and outcome of patients with isolated type II endoleaks following infra-renal EVAR.
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Affiliation(s)
- Andrew Brown
- Department of Vascular Surgery, Queens Medical Centre, University of Nottingham, Nottingham, UK
| | - Greta K Saggu
- Department of Vascular Surgery, Queens Medical Centre, University of Nottingham, Nottingham, UK
| | - Matthew J Bown
- Department of Cardiovascular Sciences, National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, University of Leicester, Leicester, UK
| | - Robert D Sayers
- Department of Cardiovascular Sciences, National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, University of Leicester, Leicester, UK
| | - David A Sidloff
- Department of Vascular Surgery, Queens Medical Centre, University of Nottingham, Nottingham, UK; Department of Cardiovascular Sciences, National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, University of Leicester, Leicester, UK
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