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Hohri Y, Kawajiri H, Kanda K, Numata S, Kobayashi T, Nakai R, Yaku H. Side-by-side deployment of gore excluder legs at a narrow terminal aorta for endovascular aneurysm repair. J Artif Organs 2024; 27:238-246. [PMID: 37227546 DOI: 10.1007/s10047-023-01406-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 05/16/2023] [Indexed: 05/26/2023]
Abstract
PURPOSE A narrow terminal aorta is a risk factor for endograft occlusion after endovascular aneurysm repair. To minimize limb complications, we used Gore Excluder legs positioned side-by-side at the terminal aorta. We investigated the outcomes of our strategy for endovascular aneurysm repair in patients with a narrow terminal aorta. METHODS We enrolled 61 patients who underwent endovascular aneurysm repair with a narrow terminal aorta (defined as < 18 mm in diameter) from April 2013 to October 2021. The standard procedure involves complete treatment with the Gore Excluder device. When other types of main body endografts were used, they were deployed proximal to the terminal aorta, and we used the Gore Excluder leg device in the bilateral limbs. Postoperatively, the intraluminal diameter of the legs at the terminal aorta was measured to assess the configuration. RESULTS During the follow-up period (mean: 2.7 ± 2.0 years), there were no aorta-related deaths, endograft occlusions, or leg-related re-interventions. There were no significant differences between the pre- and postoperative ankle-brachial pressure index values in the dominant and non-dominant legs (p = 0.44 and p = 0.17, respectively). Postoperatively, the mean difference rate (defined as [dominant leg diameter-non-dominant leg diameter]/terminal aorta diameter) was 7.5 ± 7.1%. The difference rate was not significantly correlated with the terminal aortic diameter, calcification thickness, or circumferential calcification (r = 0.16, p = 0.22; r = 0.07, p = 0.59; and r = - 0.07, p = 0.61, respectively). CONCLUSIONS Side-by-side deployment of Gore Excluder legs produces acceptable outcomes for endovascular aneurysm repair with a narrow terminal aorta. The endograft expansion at the terminal aorta is tolerable without influencing calcification distribution.
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Affiliation(s)
- Yu Hohri
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachi Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan.
| | - Hidetake Kawajiri
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachi Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan.
| | - Keiichi Kanda
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachi Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachi Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Takuma Kobayashi
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachi Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Rie Nakai
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachi Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachi Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
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de Athayde Soares R, Portela MVV, Amaro K, Nasser AI, Pedrosa KDL, Sacilotto R. The Enzen Trial: Analysis of EVAR Endoprosthesis Zenith and Endurant for Infrarenal Aortoiliac Aneurysms Regarding Outcomes, Endoleaks, and Reinterventions. J Endovasc Ther 2024:15266028241270895. [PMID: 39183689 DOI: 10.1177/15266028241270895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
OBJECTIVE The main objective of this paper is to analyze the outcomes regarding endoleaks, reinterventions, and death related to aneurysm complications in patients submitted to endovascular repair (EVAR) for abdominal aortoiliac aneurysm (AAA) using Endurant II (Medtronic) and Zenith Flex (Cook) endografts. METHODS This was a prospective, consecutive cohort study of patients with AAA who underwent EVAR between January 2019 and December 2022. Two groups of patients were evaluated: Group Endurant (patients submitted to EVAR with the use of Endurant II) and Group Zenith (patients submitted to EVAR with the use of Zenith Flex). RESULTS A total of 156 patients were evaluated. Group Zenith (67 patients, 42.9%) and Group Endurant (89 patients, 57.1%). The perioperative mortality was 5.1%, eight patients (six patients Group Zenith, and two patients Group Endurant, p=0.054). There were 28 patients (17.9%) submitted to urgent repair of the aneurysm (expansion or rupture), with no differences among the groups. There were 36 cases (23.1%) of later endoleak, with a higher incidence in Zenith group (23 patients, 34.3%) than Endurant group (13 patients, 14.6%, p=0.002), most of them Type II endoleak (21 patients, 13.4%). There were 12 cases of Type I endoleak, also with a higher prevalence in Zenith group (13.4%) than Endurant group (3.4%, p=0.002). Moreover, regarding limb graft occlusion (LGO), there were nine patients (5.8%), with a higher prevalence in Zenith group (9%) than Endurant group (3.4%, p=0.045). The overall survival in a Kaplan-Meier at 720 days was 82.3% in the Zenith group and 89.1% in the Endurant group, with no statistical significance among the groups (p=0.09). The freedom from reintervention rates in a Kaplan-Meier at 720 days was 82.8% in the Zenith group and 93.2% in the Endurant group (p=0.001). CONCLUSION In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, LGO and reinterventions than patients submitted to Endurant II endografts. The linear regression analysis showed that the presence of endoleaks, type of endograft device (Zenith graft) and limb graft occlusion were related to higher reintervention rates. CLINICAL IMPACT In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, limb graft occlusions and reinterventions than patients submitted to Endurant II endografts. The main impact and the innovation that this article provides is an opportunity to evaluate and choose the best endograft suitable for the patient with AAA during EVAR.
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Affiliation(s)
- Rafael de Athayde Soares
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Matheus Veras Viana Portela
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Kaline Amaro
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Ana Izabel Nasser
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Keityane de Lima Pedrosa
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Roberto Sacilotto
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
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Soares RDA, Amaro K, Nasser AI, Cury MVM, Nakamura ET, Pedrosa KDL, Sacilotto R. Endovascular repair for infra-renal aortic aneurysms with supra-renal fixation endoprosthesis: Results and outcomes. Vascular 2024:17085381241264381. [PMID: 39030072 DOI: 10.1177/17085381241264381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2024]
Abstract
OBJECTIVE The main objective of this paper is to evaluate the outcomes regarding endoleaks, reinterventions, and death related to aneurysm complications in patients submitted to endovascular repair (EVAR) for abdominal aortoiliac aneurysm (AAA) using Endurant II (Medtronic) and Zenith Flex (Cook) endografts. METHODS This was a prospective, consecutive cohort study of patients with AAA who underwent EVAR with the use of Endurant II stent graft and Zenith Flex endograft. RESULTS A total of 156 patients submitted to EVAR were evaluated. The perioperative mortality was 5.1%, 8 patients. The median clinical follow-up period was 760 ± 80 days. There were 28 patients (17.9%) submitted to urgent repair of the aneurysm (symptomatic expansion or rupture) and 128 patients (82.1%) submitted to elective repair. There were 36 cases (23.1%) of later endoleak and most of them are Type II endoleaks (21 patients, 13.4%). There were 12 cases of Type I endoleak. Moreover, regarding limb graft occlusion (LGO), there were 9 patients (5.8%). The overall survival rate in Kaplan-Meier analysis at 720 days was 84.8% in the total cohort. The freedom from reintervention rate in Kaplan-Meier analysis at 720 days was 92.7% in the total cohort. The linear regression analysis for survival rates showed that chronic kidney disease (p = .03; hazard ratio (HR) = 2.82, CI = 1.07-4.44) was the only factor related to poorer survival rates in both univariate and multivariate analyses. The linear regression analysis showed that the presence of endoleaks (p < .001, HR = 6.69, CI = 2.26-8.48) and limb graft occlusion (p < .001, HR = 8.02, CI = 1.60-9.99) were related to reintervention in both univariate and multivariate analyses. CONCLUSION In this present study, supra-renal fixation endograft devices were safe and efficient in treating AAA, with satisfactory results and no renal compromise. The linear regression analysis showed that the presence of endoleaks and limb graft occlusion were related to higher reintervention rates in both univariate and multivariate analyses.
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Affiliation(s)
- Rafael de Athayde Soares
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Kaline Amaro
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Ana Isabel Nasser
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Marcus Vinícius Martins Cury
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Edson Takamitsu Nakamura
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Keityane de Lima Pedrosa
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Roberto Sacilotto
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
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Papazoglou DD, Béguin M, Ricchiuto M, Jungi S, Weiss S, Helfenstein F, Bosiers MJ, Kotelis D, Makaloski V. Reintervention Rate after Treatment with the INCRAFT AAA Ultra-Low-Profile Stent Graft System. Ann Vasc Surg 2024; 109:216-224. [PMID: 39019258 DOI: 10.1016/j.avsg.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/09/2024] [Accepted: 05/12/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND The INCRAFT stent graft system is an ultra-low-profile endograft for the exclusion of infrarenal aortic aneurysms. In the market approval studies, an increased rate of device-related complications was observed and the endograft was approved with mandated postmarketing investigations. Our aim was to analyze mid-term outcomes of a real-world patient cohort treated with the INCRAFT endograft. METHODS Consecutive patients treated with the INCRAFT endograft between February 2015 and December 2022 at a single institution were included. In accordance with the Society for Vascular Surgery reporting standards, safety endpoints were reported and outcome endpoints included reinterventions, technical success, aortic-related and overall-mortality, endoleak, stent fracture, and endograft migration >5 mm. RESULTS Eighty patients (85% male) with a mean age of 76 ± 7 years were included. Fifty-two patients (65%) were treated within the endograft's instruction for use. Mean aortic diameter was 59 ± 10 mm and 91% of the procedures were performed percutaneously. Mean follow-up (FU) was 37 ± 25 months and there was no aortic- or procedure-related mortality. Reinterventions occurred in 25 patients (31%) with a freedom from reintervention at 1, 3, and 5 years of 84%, 66%, and 55%. The most frequent reinterventions were limb graft stenting (23%) and type II endoleak embolization (14%). Limb occlusion rate was 9% and in 3 patients (4%) distal endograft migrations >5 mm occurred. Persisting type II endoleaks were observed in 29% and aneurysm diameter was stable in 41% and had shrunk in 38%. Three type III endoleaks (4%) developed during FU and 4 open conversions (5%) were necessary. No known risk factors, including treatment outside instruction for use, were predictive for reinterventions. CONCLUSIONS Treatment of infrarenal aortic aneurysms with the INCRAFT stent graft system was safe and successful. Nevertheless, a substantial rate of reinterventions was necessary during FU to maintain endograft patency and prevent aneurysm growth.
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Affiliation(s)
| | - Mathieu Béguin
- Department of Vascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mario Ricchiuto
- Department of Vascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Silvan Jungi
- Department of Vascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Salome Weiss
- Department of Vascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabrice Helfenstein
- Department of Vascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Angiology, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Michel Joseph Bosiers
- Department of Vascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drosos Kotelis
- Department of Vascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Vascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
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Puvvala GK, Loukas K, Donas KP, Hinkelmann J, Faiz BF, Gerado LV, Psyllas A. Hybrid Approach: Combining Surgical Thrombectomy and AngioJet™ Aspirational Thrombectomy in Limb Graft Occlusion Post-FEVAR with Fenestrated Anaconda™ and in ePTFE Bypass Graft Occlusion. J Clin Med 2024; 13:4002. [PMID: 39064043 PMCID: PMC11277681 DOI: 10.3390/jcm13144002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/18/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
Acute limb ischemia due to limb-graft occlusion (LGO) after fenestrated endovascular aneurysm repair (FEVAR) and acute bypass graft occlusion with an ePTFE graft pose critical challenges, necessitating prompt intervention to prevent limb loss. This paper discusses two cases of acute limb ischemia treated with a hybrid approach using the AngioJet™ Ultra Thrombectomy System as an adjunct to Fogarty thrombectomy. Case I involved a 69-year-old male post-FEVAR with contralateral iliac limb graft occlusion of the fenestrated Anaconda™, while Case II featured a 70-year-old male (ASA IV) post-bypass surgery (iliopopliteal arterial bypass with ePTFE Graft) with acute bypass graft occlusion. Both cases underwent successful recanalization using the AngioJet™ Ultra Thrombectomy System (ZelanteDVT™ 8F catheter, Solent™ Proxi 6F catheter) (Boston Scientific, Marlborough, MA, USA), combined with adjunctive techniques including Fogarty thrombectomy, balloon angioplasty, stenting, and local lysis. Immediate postoperative and follow-up assessments after 6 months revealed restored limb perfusion and improved clinical outcomes, with palpable pulses and improved ulcer healing. The aim of this treatment strategy is not only to alleviate limb ischemia but also to preserve future options in the event of graft failure. The use of the AngioJet™ Thrombectomy System in cases of LGO aims not only to clear the thrombus load but also to avoid the need for graft relining. In the case of acute arterial bypass graft occlusion in a patient with ASA IV, the goal of using the thrombectomy device is to preserve the native vessels for future procedures, such as long infragenual bypass, in addition to limb salvage. These cases demonstrate the efficacy of a hybrid surgical approach in managing acute limb ischemia following graft occlusion following FEVAR and bypass surgery. Long-term follow-up will further elucidate the durability of these interventions and their impact on limb salvage and overall patient outcomes. By combining mechanical thrombectomy with adjunctive techniques, such as balloon angioplasty and stenting, this hybrid approach offers a comprehensive solution to acute limb ischemia, addressing both the underlying occlusive pathology and ensuring optimal limb perfusion. Furthermore, the utilization of the AngioJet™ Ultra Thrombectomy System provides a minimally invasive yet effective method for thrombus removal, reducing procedural time and potential complications associated with open surgical techniques. As such, this approach represents a valuable addition to the armamentarium of treatments for acute limb ischemia, particularly in cases of graft occlusion following complex endovascular and bypass procedures.
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Affiliation(s)
| | | | | | | | - Ba-Fadhl Faiz
- Department of Vascular Surgery, Marien Hospital, 46483 Wesel, Germany
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6
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Roy J, Siika A. Higher Risk of Limb Graft Occlusions: The Achilles Heel of the Zenith Alpha Abdominal Endovascular Graft. Eur J Vasc Endovasc Surg 2024; 68:49. [PMID: 38642604 DOI: 10.1016/j.ejvs.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 03/28/2024] [Accepted: 04/16/2024] [Indexed: 04/22/2024]
Affiliation(s)
- Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Antti Siika
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm Sweden
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Hatzl J, van Basten Batenburg M, Yeung KK, Fioole B, Verhoeven E, Lauwers G, Kölbel T, Wever JJ, Scheinert D, Van den Eynde W, Rouhani G, Mees BME, Vermassen F, Schelzig H, Böckler D, Cuypers PWM. Clinical Performance of the Low Profile Zenith Alpha Abdominal Endovascular Graft: 2 Year Results from the ZEPHYR Registry. Eur J Vasc Endovasc Surg 2024; 68:40-48. [PMID: 38490356 DOI: 10.1016/j.ejvs.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 02/26/2024] [Accepted: 03/08/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVE The midterm outcomes of the low profile Zenith Alpha Abdominal Endovascular Graft from the ZEnith alPHa for aneurYsm Repair (ZEPHYR) registry are reported. METHODS The ZEPHYR registry is a physician initiated, multicentre, non-randomised, core laboratory controlled, prospective registry. Inclusion criteria were patients with a non-ruptured abdominal aortic aneurysm with a maximum diameter ≥ 50 mm or enlargement > 5 mm within 6 months, with a site reported infrarenal neck length of ≥ 10 mm and with the intention to electively implant the Zenith Alpha abdominal endograft. Patients from 14 sites across Germany, Belgium, and the Netherlands were included. The primary endpoint was treatment success, defined as technical success and clinical success. Technical success was defined as successful delivery and deployment of the endograft in the planned position without unintentional coverage of internal iliac or renal arteries, with successful removal of the delivery system. Clinical success was defined as freedom from aneurysm sac expansion > 5 mm, type I or type III endoleaks, aneurysm rupture, stent graft migration > 10 mm, open conversion, and stent graft occlusion. RESULTS Three hundred and forty-seven patients were included in the ZEPHYR registry. The median clinical follow up was 743 days (interquartile range [IQR] 657, 806) with a median imaging follow up of 725 days (IQR 408, 788). Treatment success at 6 months, 1, and 2 years was 92.5%, 90.4%, and 85.3%, respectively. Freedom from secondary intervention was 94.3%, 93.4%, and 86.9%, respectively. The predominant reason for secondary intervention was limb complications. Freedom from limb occlusion (per patient) at 6 months, 1, and 2 years was 97.2%, 95.8%, and 92.5%, respectively. Univariable and multivariable Cox regression analyses could not identify any independent predictor for limb complications. CONCLUSION While treatment success is comparable with other commercially available grafts, the rate of limb complications at 2 years is of concern. The manufacturer's instructions for use should be followed closely. Further studies are necessary to investigate the root cause of the increased rate of limb complications with the Zenith Alpha Abdominal Endovascular Graft.
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Affiliation(s)
- Johannes Hatzl
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany.
| | | | - Kak K Yeung
- Department of Vascular Surgery, Amsterdam UMC, Location VU Medical Centre, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Eric Verhoeven
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Geert Lauwers
- Department of Vascular and Thoracic Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Tilo Kölbel
- German Aortic Centre Hamburg, Department of Vascular Medicine, University Medical Centre Eppendorf, Hamburg, Germany
| | - Jan J Wever
- Departments of Vascular Surgery and Interventional Radiology, Haga Hospital, The Hague, the Netherlands
| | - Dierk Scheinert
- Department of Angiology, University Hospital Leipzig, Leipzig, Germany
| | - Wouter Van den Eynde
- Department of Vascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
| | - Guido Rouhani
- Section of Vascular and Endovascular Surgery, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Barend M E Mees
- Department of Vascular Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Frank Vermassen
- Department of Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Hubert Schelzig
- Department of Vascular and Endovascular Surgery, Heinrich-Heine-University Medical Centre Düsseldorf, Düsseldorf, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
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Essam S, Hussein M, Ahmed AM, Ahmed L, Gaber H, El-Masry H, Abdelaal RM, Galal N, Kassem A, Shaalan W. Safety Evaluation of Unibody Endografts for Abdominal Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2024; 108:437-451. [PMID: 38960091 DOI: 10.1016/j.avsg.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 04/05/2024] [Accepted: 04/13/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND The unibody bifurcated aortic endograft (AFX/AFX2) has emerged as a treatment option for abdominal aortic aneurysms (AAAs). This systematic review and meta-analysis aimed to evaluate the safety of the unibody endograft. METHODS A literature search was conducted in Cochrane Library, Scopus, Web of Science, and PubMed. Studies assessing the unibody endograft for AAA repair between 2014 and 2023 were included. The defined primary outcomes were the incidences of type I, II, and III endoleaks. The secondary outcomes were access site problems, aneurysm-related mortality, aneurysm rupture, all-cause mortality, aneurysm sac growth, limb occlusion, stent graft migration, and technical success rate. RESULTS Fourteen studies including 12 observational studies and 2 randomized controlled trials were included in the systematic review. The meta-analysis included 10 studies with 12,690 patients that reported the measured outcomes, and excluded 4 studies that did not. Type II endoleaks had the highest incidence of 12% (95% confidence interval [CI]: 4-20%), followed by type III endoleaks with an incidence of 3% (95% CI: 1-5%). The incidence of type I endoleaks was 1% (95% CI: 0-2%). A subgroup analysis by follow-up duration showed that type II endoleak incidence was higher after 1 to 2 years of follow-up than 3 to 4 years of follow-up. The incidence of aneurysmal mortality was 2% (95% CI: 0-7%), limb occlusion was 1% (95% CI: 0-1%), stent graft migration was 1% (95% CI: 0-2%), aneurysmal rupture was 6% (95% CI: 2-11%), access site problems were 7% (95% CI: 2-13%), aneurysm sac growth was 2% (95% CI: 0-4%), all-cause mortality was 21% (95% CI: 4-38%), and technical success rate was 100% (95% CI: 98-100%). CONCLUSIONS The unibody endograft is a safe and minimally invasive approach for AAA repair. However, potential complications necessitate close patient follow-up after the intervention.
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Affiliation(s)
- Safia Essam
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mirna Hussein
- Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | | | - Lujaina Ahmed
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Hamed Gaber
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Hassan El-Masry
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Nourhan Galal
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Kassem
- Faculty of Medicine, Vascular and Endovascular Surgery Unit, Alexandria University, Alexandria, Egypt
| | - Wael Shaalan
- Faculty of Medicine, Vascular and Endovascular Surgery Unit, Alexandria University, Alexandria, Egypt
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9
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Pini R, Bianchini Massoni C, Faggioli G, Caputo S, Sufali G, Ancetti S, Vacirca A, Gallitto E, Perini P, Freyrie A, Gargiulo M. Cook Zenith Alpha Endograft: A Protocol to Minimise Limb Graft Occlusion. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00553-7. [PMID: 38936689 DOI: 10.1016/j.ejvs.2024.06.036] [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: 12/08/2023] [Revised: 05/21/2024] [Accepted: 06/19/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVE Numerous articles have reported an increased incidence of limb graft occlusion (LGO) with the Cook Zenith Alpha endograft compared with other endografts in endovascular aortic aneurysm repair (EVAR). The present study aimed to assess the rate of LGO after EVAR in particular with the Cook Zenith Alpha device when adhering to a standardised protocol designed to prevent limb related complications. METHODS This was a non-sponsored retrospective study performed in two university vascular surgery centres employing the same protocol for limb complication prevention during EVAR from 2016 to 2019. The protocol encompassed: (1) angioplasty of any common or external iliac artery with > 50% stenosis before endograft navigation; (2) proximal sealing zone of limbs at the same level of the flow divider with minimum overlap, which is more restrictive than the Cook Zenith Alpha instructions for use; (3) semi-compliant kissing ballooning of limbs; (4) limb stenting for any residual tortuosity, kinking, or stenosis; and (5) adjunctive common and external iliac stenting for residual stenosis or dissection after EVAR. Patients enrolled in this study were treated with standard aortobi-iliac EVAR. Follow up was performed by clinical visit and duplex ultrasonography at discharge, six months, and yearly thereafter. The primary endpoint was to evaluate the LGO rate with different EVAR devices (Cook Zenith Alpha, Gore C3, and Medtronic Endurant) and to determine potential risk factors for LGO associated with the Zenith Alpha. RESULTS In the study period, 547 EVARs were considered: 233 (42.6%) Cook Zenith Alpha, 196 (35.8%) Gore Excluder, and 118 (21.6%) Medtronic Endurant. The mean follow up was 44 ± 23 months, and the five year freedom from LGO was 97 ± 3%, without differences between groups (97 ± 2%, 95 ± 3%, and 100% with Cook Zenith Alpha, Medtronic Endurant, and Gore Excluder, respectively; p = .080). In the Zenith Alpha group, intra-operative adjunctive iliac artery angioplasty, iliac artery stenting, or iliac limb stenting was performed in 8%, 3.4%, and 9.7% of cases, respectively. Analysis of potential risk factors for LGO identified external iliac artery distal landing and large main bodies (ZIMB 32 - 36) to be independently associated with LGO during follow up (hazard ratio [HR] 18, 95% confidence interval [CI] 3 - 130, p = .004; and HR 12, 95% CI 1.2 - 130, p = .030, respectively). CONCLUSION The present experience with a protocol for limb complication prevention allows achievement of a low rate of LGO at five years with Zenith Alpha endografts similar to other endografts. Specific risk factors for the Cook Zenith Alpha endograft are external iliac artery distal landing and the use of a large main body (ZIMB 32 - 36).
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Affiliation(s)
- Rodolfo Pini
- Vascular Surgery Unit, IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy; Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy.
| | - Claudio Bianchini Massoni
- Vascular Surgery Unit, Azienda Ospedaliero-Universitaria di Parma, Università di Parma, Parma, Italy
| | - Gianluca Faggioli
- Vascular Surgery Unit, IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy; Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy
| | - Stefania Caputo
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy
| | - Gemmi Sufali
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy
| | - Stefano Ancetti
- Vascular Surgery Unit, IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Andrea Vacirca
- Vascular Surgery Unit, IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy; Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy
| | - Enrico Gallitto
- Vascular Surgery Unit, IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy; Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy
| | - Paolo Perini
- Vascular Surgery Unit, Azienda Ospedaliero-Universitaria di Parma, Università di Parma, Parma, Italy
| | - Antonio Freyrie
- Vascular Surgery Unit, Azienda Ospedaliero-Universitaria di Parma, Università di Parma, Parma, Italy
| | - Mauro Gargiulo
- Vascular Surgery Unit, IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy; Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy
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10
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Chaudhuri A, Abisi S, Badawy A. Percutaneous mechanical thrombectomy for limb graft occlusion after endovascular aneurysm repair: Results of a case series. Vascular 2024; 32:546-549. [PMID: 36724505 DOI: 10.1177/17085381231155670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Limb graft occlusion (LGO) is a recognised complication after endovascular aneurysm repair (EVAR). We present outcomes of a case series of LGO treated by percutaneous mechanical thrombectomy (PMT). METHODS Six male patients (mean age 70.5 ± 7.5 years) presented with LGO after EVAR (n = 4), fenestrated EVAR with an iliac branch device (n = 1), branched EVAR (n = 1). Median time to occlusion was 28.5(IQR 90) weeks; all occlusions were unilateral. The presenting symptom was intermittent claudication (n = 4), chronic limb-threatening ischaemia (n = 1) or acute limb ischaemia (n = 1). PMT was undertaken using the 10F Rotarex Rotational Excisional Atherectomy System (Becton, Dickinson and Company, Franklin Lakes, USA) with optional stenting/reline of the affected limb. RESULTS LGO was cleared in all 6 cases by PMT with limb stenting (n = 4)/limb reline (n = 2)/outflow stenting (n = 2). Post-operatively, novel oral anticoagulant therapy supplemented prior antiplatelet therapy in all cases. Length of stay was 2 (IQR 19) days. All cleared limbs remain patent at median 15 (IQR 185) weeks follow-up. CONCLUSION This case series indicates that percutaneous mechanical thrombectomy is associated with high technical success rates and subsequent acceptable ensuing short-to-midterm patency. This approach is a valid alternative to surgical interventions in such cases, and represents our primary approach when LGO is encountered after EVAR.
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Affiliation(s)
- Arindam Chaudhuri
- Bedfordshire - Milton Keynes Vascular Centre, Bedford Hospital NHS Trust, Bedford, UK
| | | | - Ayman Badawy
- Bedfordshire - Milton Keynes Vascular Centre, Bedford Hospital NHS Trust, Bedford, UK
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11
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Yuan Z, Du C, You Y, Wang J. Predictive Factors for Iliac Limb Occlusions After Endovascular Abdominal Aneurysm Repair: Determined from Aortoiliac Anatomy, Endovascular Procedures, and Aneurysmal Remodeling. Ther Clin Risk Manag 2024; 20:297-311. [PMID: 38799513 PMCID: PMC11122200 DOI: 10.2147/tcrm.s459594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/16/2024] [Indexed: 05/29/2024] Open
Abstract
Purpose Iliac limb occlusion (ILO) is a serious complication of endovascular abdominal aneurysm repair (EVAR). This study aimed to identify predictive factors for ILO derived from aortoiliac morphology, endovascular procedure-related parameters, and aneurysmal remodeling characteristics. Patients and Methods Patient demographics, pre-EVAR anatomical characteristics of the aneurysm, endovascular procedure details, and post-EVAR aneurysmal remodeling outcomes were analyzed and compared using univariate analysis. Statistically significant factors were subsequently subjected to Cox regression and Kaplan-Meier analyses. Results Between January 2013 and April 2022, 66 patients were included in this study. Fourteen patients presented with ILO and were compared with 52 control patients with patent endograft limb over at least 1-year of follow-up. The tortuosity indices of the common iliac artery (CIA) and endograft iliac limb to vessel oversizing were significantly larger in the ILO group than in the patent endograft limb group. The CIA index of tortuosity ≥1.08, and endograft iliac limb to vessel oversizing ≥18.8% were independent predictors for ILO. During the follow-up of all patients, the proximal aortic neck and CIA diameters increased, aneurysm sac diameter decreased, and aortic neck and aortic length increased. The aortoiliac length increased over time in patients with patent endograft limb but not in patients with ILO. A change in the lowest renal artery-left iliac bifurcation distance ≦0.07 mm increased the risk of ILO. Conclusion ILO is predisposed to occur when the CIA index of tortuosity ≥1.08 and endograft iliac limb to vessel oversizing ≥18.8% are present. Significant aortoiliac remodeling, including proximal aortic neck dilatation, neck straightening, aneurysmal sac regression, iliac artery enlargement, and aortic lengthening, occurs after EVAR. Aortoiliac elongation was observed in patients with patent endograft limb, but not in patients with ILO. ILO was associated with a change in the lowest renal artery-left iliac bifurcation from the postoperative measurements ≦ 0.07 mm.
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Affiliation(s)
- Zihui Yuan
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Chao Du
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Yun You
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Jian Wang
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
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12
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Kontes I, Bontinis V, Bontinis A, Manaki V, Chorti A, Giannopoulos A, Ktenidis K. Sequential Graft Limb Occlusion Following Endovascular Aneurysm Repair: A Case Report and Literature Review. Cureus 2024; 16:e60102. [PMID: 38860102 PMCID: PMC11164407 DOI: 10.7759/cureus.60102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2024] [Indexed: 06/12/2024] Open
Abstract
Limb graft occlusion (LGO) is a common complication that can occur after endovascular aneurysm repair (EVAR). There are many factors that can contribute to LGO, including patient-related variables, device-related considerations, and factors associated with the procedural technique. Patients with LGO may exhibit no symptoms, have intermittent claudication, or suffer from acute limb ischemia. In this manuscript, we present a case of a 64-year-old male who experienced sequential LGOs after EVAR accompanied by a comprehensive review of the pertinent literature.
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Affiliation(s)
- Ioannis Kontes
- Department of Vascular Surgery, AHEPA (American Hellenic Educational and Progressive Association) University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Vangelis Bontinis
- Department of Vascular Surgery, AHEPA (American Hellenic Educational and Progressive Association) University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Alkis Bontinis
- Department of Vascular Surgery, AHEPA (American Hellenic Educational and Progressive Association) University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Vasiliki Manaki
- Department of Vascular Surgery, AHEPA (American Hellenic Educational and Progressive Association) University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Angeliki Chorti
- Department of Surgery, AHEPA (American Hellenic Educational and Progressive Association) University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Argyrios Giannopoulos
- Department of Vascular Surgery, AHEPA (American Hellenic Educational and Progressive Association) University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Kyriakos Ktenidis
- Department of Vascular Surgery, AHEPA (American Hellenic Educational and Progressive Association) University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
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13
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Fujimura N, Ichihashi S, Shibata T, Matsumura H, Watanabe M, Morikage N, Kurimoto Y, Banno H, Uchiyama H, Obara H. Early Clinical Results From the Japanese Prospective Multicenter Study to Evaluate Zenith Alpha Abdominal Stent Graft for Abdominal Aortic Aneurysm (JUSTICE) Registry Demonstrate Acceptable Limb Patency at 12 Months. J Endovasc Ther 2024:15266028241248311. [PMID: 38654524 DOI: 10.1177/15266028241248311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE Recent reports of the Zenith Alpha abdominal endovascular graft (Zenith Alpha AAA, Cook, Inc., Bloomington, Indiana) have demonstrated an unexpectedly high incidence of limb graft occlusion (LGO). The purpose of this study was to prospectively evaluate the performance of the Zenith AAA in Japan, with a specific focus on LGO. MATERIALS AND METHODS All endovascular aneurysm repairs (EVARs) for abdominal aortic aneurysms performed using the Zenith Alpha AAA from July 2020 to October 2021 in 23 Japanese hospitals were prospectively evaluated. All computed tomographic images were analyzed in the core laboratory. Late complications were defined as any aneurysm-related events occurring >30 days after EVAR, including aneurysm sac enlargement of >5 mm and any reinterventions performed. Endoleaks without sac enlargement or reintervention were excluded as late complications. RESULTS During the study period, 147 EVARs were performed using the Zenith Alpha AAA. The mean patient age was 76.5±7.7 years, 84.4% of patients were male, and the mean aneurysm diameter was 52.4±9.2 mm. Instruction-for-use violations were observed in 76 patients (51.7%), primarily associated with a severely angulated proximal neck (>60°). There were six intraoperative complications and 62 additional intraoperative treatments reported, most of which involved preemptive coil embolization of the inferior mesenteric artery (37 cases). Technical success, defined as the absence of type 1 or 3 endoleaks on final angiography, was achieved in 99.3% of patients. At 12 months, there was only one case of type 1/3 endoleak (0.8%) and one aneurysm sac enlargement exceeding 5 mm (0.8%); however, a high incidence of type 2 endoleaks was observed in 35.2% of patients, and aneurysm sac regression exceeding 5 mm was achieved in 30.1% of patients. Nine late complications were observed, and the rate of freedom from late complications at 12 months was 93.5%, encompassing four LGOs and one limb graft stenosis (3.4%). CONCLUSIONS In contrast to recent reports, our Japanese multicenter prospective study demonstrated satisfactory early clinical results, including an acceptable LGO rate, for the low-profile Zenith Alpha AAA. Long-term follow-ups will be performed to confirm the persistence of these outcomes. CLINICAL IMPACT This study prospectively evaluated the performance of 147 Zenith Alpha AAAs used for endovascular aneurysm repair with core-lab adjudication focusing especially on limb graft occlusion (LGO). At 12 months, aneurysm sac regression exceeding 5 mm was achieved in 30.1% of patients, and there was only one type 1/3 endoleak, one aneurysm sac enlargement (>5 mm), and nine late complications including five LGOs (3.4%), resulting in rate of freedom from late complications at 93.5%. Satisfactory early clinical results, including an acceptable rate of LGO can be achieved, particularly with cautious usage of the Zenith Alpha Spiral-Z Endovascular Leg." 5mm), and nine late complications including five LGOs (3.4%), resulting in rate of freedom from late complications at 93.5%. Satisfactory early clinical results, including an acceptable rate of LGO can be achieved, particularly with cautious usage of the Zenith Alpha Spiral-Z Endovascular Leg.
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Affiliation(s)
- Naoki Fujimura
- Department of Vascular Surgery, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | | | - Tsuyoshi Shibata
- Department of Cardiovascular Surgery, Sapporo Medical University, Hokkaido, Japan
| | - Hitoshi Matsumura
- Department of Cardiovascular Surgery, School of Medicine, Fukuoka University, Fukuoka, Japan
| | - Michiko Watanabe
- Department of Cardiovascular Surgery, Chiba University, Chiba, Japan
| | - Noriyasu Morikage
- Department of Vascular Surgery, Yamaguchi University, Yamaguchi, Japan
| | - Yoshihiko Kurimoto
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Hokkaido, Japan
| | - Hiroshi Banno
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidetoshi Uchiyama
- Department of Vascular Surgery, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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14
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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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15
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Basra M, Hussain P, Li M, Kulkarni S, Stather PW, Armon M, Choksy S. Factors Related to Limb Occlusion After Endovascular Abdominal Aortic Aneurysm Repair (EVAR). Ann Vasc Surg 2024; 99:312-319. [PMID: 37858668 DOI: 10.1016/j.avsg.2023.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/03/2023] [Accepted: 08/25/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Limb occlusion is a potentially serious consequence of endovascular abdominal aortic aneurysm (EVAR). This case-control study identifies factors that predispose to limb occlusion. METHODS A consecutive series of patients from 2 centers undergoing EVAR over an 11-year period 2007-2017 were identified retrospectively. Patient records were interrogated allowing collations of demographics, intraoperative and perioperative data and surveillance data. The preoperative computed tomography angiogram was analyzed to determine EVAR relevant anatomical data. The primary outcome was occlusion of the iliac limb of the implanted EVAR. Raw data are presented as percentages, with comparative data analyzed using Mann-Whitney U-test and binomial logistic regression. RESULTS A total of 787 patients (702 males; median age 78 years, range 53-94 years old) were analyzed. Fifty patients reached the primary outcome, resulting in an overall limb occlusion rate of 6.35%. Factors predictive of limb occlusion were oversizing by >10% native vessel diameter, with oversizing of >20% in 50% of those that occluded. External iliac artery landing zone (12/50 limb occlusions) 24% and postoperative kinking (5/50 limb occlusions) 10% were also more common in those that occluded. Fifty randomly selected controls with similar baseline characteristics were studied. Oversizing of the iliac endograft was found to be significantly greater in the limb occlusion group compared to the controls (P < 0.001) which remained significant on regression analysis. There was no correlation with iliac tortuosity. The Cook stent graft had a 9% limb occlusion rate across sites. Medtronic and Vascutek endografts had 2.4% and 2.5% limb occlusion rates respectively. CONCLUSIONS Oversizing of iliac limbs by >20% could be a contributing factor to limb occlusion after EVAR and judicious oversizing should be used.
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Affiliation(s)
- Melvinder Basra
- Vascular Surgery Department, Colchester University Hospital Foundation Trust, Colchester, UK; Vascular Surgery Department, Norfolk and Norwich University Hospital, Norwich, UK.
| | - Parvez Hussain
- Vascular Surgery Department, Colchester University Hospital Foundation Trust, Colchester, UK
| | - Mimi Li
- Vascular Surgery Department, Norfolk and Norwich University Hospital, Norwich, UK
| | - Shreya Kulkarni
- Vascular Surgery Department, Norfolk and Norwich University Hospital, Norwich, UK
| | - Philip W Stather
- Vascular Surgery Department, Norfolk and Norwich University Hospital, Norwich, UK; Norwich Medical School, University of East Anglia, Norwich, UK
| | - Matthew Armon
- Vascular Surgery Department, Norfolk and Norwich University Hospital, Norwich, UK
| | - Sohail Choksy
- Vascular Surgery Department, Colchester University Hospital Foundation Trust, Colchester, UK
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16
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
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.
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González Canga C, Alonso Pastor A, Zanabili Al-Sibbai A, Vaquero Lorenzo F, Álvarez Marcos F, Alonso Pérez M. Aneurysm Sac Shrinkage After EVAR Can Lead to Complications: A Case Report of Complete Endograft Thrombosis Due to Kinking. Vasc Endovascular Surg 2024; 58:105-109. [PMID: 37437582 DOI: 10.1177/15385744231189019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
BACKGROUND Bilateral limb occlusion after endovascular repair of abdominal aortic aneurysms (EVAR) is an uncommon entity. The relationship between graft kinking and unilateral limb occlusion is widely described in the literature. Our aim is to report a case of complete endograft thrombosis due to bilateral limb kinking secondary to aneurysm sac shrinkage, treated by endovascular means. CASE REPORT A 67 year-old male with history of EVAR with an Incraft® endograft (Cordis, Bridgewater, NJ, USA) four years before, presented at the emergency department with disabling claudication of the right lower extremity and a better tolerated 10-month left extremity claudication. Complete endograft thrombosis with bilateral limb kinking and a remarkable reduction of the aneurysm sac was observed in the computed tomography angiography. An endovascular repair was performed, through bilateral open femoral access and with angiographic control through percutaneous left brachial access. Bilateral recanalization was achieved and the endograft was re-lined with two 10x150 mm Viabahn (WL Gore & Ass., Flagstaff, AZ, USA). Both sides were extended with a 11 × 50 mm Viabahn (WL Gore & Ass., Flagstaff, AZ, USA). The final angiographic control showed bilateral patency with no residual stenosis and the patient recovered distal pulses. Follow-up showed complete patency and no complications at 17 months. CONCLUSIONS Bilateral limb occlusion is a rare complication with technically challenging treatment options. Aneurysm sac shrinkage can affect the endograft configuration, leading to limb distortion and occasionally to bilateral limb occlusion after EVAR. Special attention should be put on imaging follow-up to detect these complications before occlusion occurs.
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Affiliation(s)
- Carmen González Canga
- Department of Vascular Surgery, Asturias University Central Hospital (HUCA), Oviedo, Spain
| | - Alba Alonso Pastor
- Department of Vascular Surgery, Asturias University Central Hospital (HUCA), Oviedo, Spain
| | | | | | - Francisco Álvarez Marcos
- Department of Vascular Surgery, Asturias University Central Hospital (HUCA), Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Manuel Alonso Pérez
- Department of Vascular Surgery, Asturias University Central Hospital (HUCA), Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
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18
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Simmering JA, de Vries M, Haalboom M, Reijnen MMPJ, Slump CH, Geelkerken RH. Geometrical Changes of the Aorta as Predictors for Thromboembolic Events After EVAR With the Anaconda Stent-Graft. J Endovasc Ther 2023; 30:904-919. [PMID: 35786215 PMCID: PMC10637097 DOI: 10.1177/15266028221105839] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Thromboembolic events (TE), including limb graft occlusion (LGO) and distal limb embolization (DLE), are common complications after endovascular aneurysm repair (EVAR). The aim of this study was to find predictors for TE in patients treated with the Anaconda stent-graft for infrarenal aneurysms. MATERIALS AND METHODS Geometrical and anatomical variables were retrospectively analyzed in a consecutive Anaconda cohort. Pre- and postoperative CT scans were used to derive geometrical parameters length, curvature, torsion, and tortuosity index (TI) from the center lumen lines (CLLs). Limb characteristics, pre-to-post EVAR and mid-term-follow-up changes in the parameters were evaluated for their predictive value for TE. RESULTS Eighty-four patients (mean age 74±8.3 years, 74 men) were enrolled. The risk of TE was lowered with pre-to-post implant decreasing TI (steps of 0.05: OR: 1.30, 95% CI: 1.01-1.66, p=0.04), pre-to-post implant decreasing mean curvature (OR: 1.08, 95% CI: 1.01-1.16, p=0.03), and a larger degree of circumferential common iliac artery (CIA) calcification (OR: 0.98, 95% CI: 0.97-1.00, p=0.03). The only LGO predictor was the caudal relocation of maximal curvature after EVAR (OR: 1.01, 95% CI: 1.00-1.01, p=0.04). Preventors of DLE were CIA diameter (OR: 0.87, 95% CI: 0.76-0.99, p=0.04), circumferential CIA calcification (OR: 0.97, 95% CI: 0.95-1.00, p=0.03), mean and maximal curvature of the preoperative aortoiliac trajectory (OR: 0.86, 95% CI: 0.79-0.94, p<0.01 and OR: 0.97, 95% CI: 0.95-1.00, p=0.03, respectively) and pre-to-postoperative decrease in mean curvature (OR: 1.11, 95% CI: 1.02-1.21, p=0.02). Midterm TE predictors were length (OR: 0.95, 95% CI: 0.89-1.01, p=0.08) and torsion maximum location (OR: 1.01, 95% CI: 0.99-1.01, p=0.10). CONCLUSION The present study confirms that treatment of infrarenal AAA with an Anaconda stent-graft is related to a relatively high TE rate which decreases with a pre-to-postoperative reduction in curvature and TI, and a larger degree of circumferential CIA calcification. In other words, more aortoiliac straightening and more circumferential CIA calcification may prevent TE development after EVAR with this stent-graft.
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Affiliation(s)
- Jaimy A. Simmering
- Division of Vascular Surgery, Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
- Multi-Modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Mattijs de Vries
- Division of Vascular Surgery, Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Marieke Haalboom
- Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Michel M. P. J. Reijnen
- Multi-Modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
- Division of Vascular Surgery, Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Cornelis H. Slump
- Robotics and Mechatronics (RaM) Group, Faculty of Electrical Engineering, Mathematics and Computer Science, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Robert H. Geelkerken
- Division of Vascular Surgery, Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
- Multi-Modality Medical Imaging (M3i) Group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, The Netherlands
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Torsello G, Bertoglio L, Kellersmann R, Wever JJ, van Overhagen H, Stavroulakis K. Three-Year Safety and Efficacy of the INCRAFT Endograft for Treatment of Abdominal Aortic Aneurysms: Results of the INSIGHT Study. J Endovasc Ther 2023:15266028231214162. [PMID: 38031973 DOI: 10.1177/15266028231214162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
PURPOSE Preliminary results of the INSIGHT study showed that the low-profile INCRAFT Abdominal Aortic Aneurysm (AAA) Stent-Graft System was safe and effective in the endovascular aneurysm repair (EVAR). This study aimed to assess the durability and the midterm effectiveness of EVAR using the INCRAFT System in the framework of a multicenter, prospective, open-label, post-approval study. MATERIALS AND METHODS Between 2015 and 2016, 150 subjects from 23 European centers treated with the INCRAFT System for an infrarenal AAA were included. Clinical and radiologic data were prospectively collected and analyzed using protocol-specified, monitored follow-up clinic visits at 1, 6, and 12 months post-implantation and annually after that. The clinical success at 3 years was determined. Freedom from overall and aneurysm-related mortality, type I endoleak, secondary interventions, and aneurysm sac enlargement through 3 years were evaluated. Kaplan-Meier estimates were used for late outcomes. An independent clinical events committee reviewed all events. The CT (computed tomography) scans through 1 year were reviewed by an independent core laboratory. RESULTS The primary clinical success rate at 3 years was 84.0% (126/150). There were no aneurysm-related deaths, endograft migration, or aneurysm-related ruptures through 3 years. Stent fracture was detected in 2 subjects (1.3%) without clinical sequelae. Over 3 years, freedom from overall mortality was 89.4%, freedom from secondary interventions was 80%, and freedom from aneurysm sac enlargement was 96.5%. The 3-year freedom from type IA and IB endoleaks was 93.3% and 98.6%, respectively. CONCLUSIONS. In a multicenter real-world study setting, the use of a low-profile INCRAFT device for AAA is associated with sustained clinical success and low rates of reinterventions through 3 years. CLINICAL IMPACT Low-profile endografts have broadened the spectrum of patients with anatomic suitability for endovascular repair of abdominal aortic aneurysms (AAA). However, questions remain regarding the durability of the repair. The INSIGHT study evaluated the use of the INCRAFT System in routine real-world clinical practice, including patients with complex anatomies. The treatment was safe and effective. The results showed sustained clinical success over 3 years, with no aneurysm-related deaths or ruptures, and a high rate of intervention-free survival at 3 years. Despite the low-profile design of the endograft, the midterm results demonstrate the durability of AAA repair using the INCRAFT System.ClinicalTrials.gov Identifier: NCT02477111.
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Affiliation(s)
- Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus Hospital, Muenster, Germany
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Richard Kellersmann
- Clinic and Polyclinic for General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Jan J Wever
- Department of Vascular Surgery & Interventional Radiology, Haga Hospital, The Hague, The Netherlands
| | - Hans van Overhagen
- Department of Vascular Surgery & Interventional Radiology, Haga Hospital, The Hague, The Netherlands
| | - Konstantinos Stavroulakis
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany
- Department of Vascular and Endovascular Surgery, Ludwig-Maximilian-University Hospital, Munich, Germany
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Dias-Neto M, Oliveira-Pinto J. We're Crossing a Turbulent Zone, Fasten Your Seatbelts! Eur J Vasc Endovasc Surg 2023; 66:652. [PMID: 37582421 DOI: 10.1016/j.ejvs.2023.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/28/2023] [Accepted: 08/09/2023] [Indexed: 08/17/2023]
Affiliation(s)
- Marina Dias-Neto
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal.
| | - José Oliveira-Pinto
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar De Trás-Os-Montes E Alto Douro, E.P.E, Vila Real, Portugal
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Ulsaker H, Lam M, Herje ML, Seternes A, Manstad-Hulaas F. A Retrospective Evaluation of Intra-Prosthetic Thrombus Formation After Endovascular Aortic Repair in Cook Zenith Alpha and Medtronic Endurant II Patients. Eur J Vasc Endovasc Surg 2023; 66:644-651. [PMID: 37286099 DOI: 10.1016/j.ejvs.2023.05.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/25/2023] [Accepted: 05/31/2023] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To investigate the occurrence of limb graft occlusion (LGO) and intra-prosthetic thrombus (IPT) formation in Zenith Alpha and Endurant II stent graft limbs. METHODS A single centre retrospective study was conducted on patients treated with the Zenith Alpha and Endurant II stent grafts between 2017 and 2019. All post-operative computed tomography angiography images were re-investigated for thrombus formation. Demographic, aneurysm, and stent graft data were collected and compared. LGO was defined as complete occlusion or significant stenosis (≥ 50% lumen diameter reduction). Logistic regression on pro-thrombotic risk factors was conducted. Freedom from LGO and overall limb IPT were compared using Kaplan-Meier analyses. RESULTS Seventy-eight Zenith Alpha and eighty-six Endurant II patients were studied. The median follow up was 33 (IQR 25, 44) months for Zenith Alpha patients and 36 (IQR 22, 46) months for Endurant II patients (p = .53). LGO was seen in 15% (n = 12) of Zenith Alpha patients and 5% (n = 4) of Endurant II patients (p = .032), and freedom from LGO was significantly higher among Endurant II patients (p = .024). The Zenith Alpha stent graft was an independent risk factor for LGO (OR 3.9, 95% CI 1.1 - 13.4; p = .032). Among Zenith Alpha patients, limb flare compression within the main body gate was over represented in LGO patients (p = .011). There was no difference in freedom from overall limb IPT between the stent graft systems. For Endurant II limbs, IPT was significantly less common in the integrated ipsilateral limbs (without ETLW/ETEW stent graft limbs) (p = .044). Main endograft body IPT was correlated with overall limb IPT (p = .035). CONCLUSION LGO was significantly more common among Zenith Alpha than Endurant II patients. Zenith Alpha limbs was an independent risk factor for LGO. There was no difference between stent grafts in overall limb IPT formation.
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Affiliation(s)
- Håvard Ulsaker
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St Olavs Hospital, Trondheim, Norway.
| | - Mina Lam
- Department of Vascular Surgery, St Olavs University Hospital, Trondheim, Norway
| | | | - Arne Seternes
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Vascular Surgery, St Olavs University Hospital, Trondheim, Norway
| | - Frode Manstad-Hulaas
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St Olavs Hospital, Trondheim, Norway; Department of Radiology, St Olavs University Hospital, Trondheim, Norway
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Jubouri M, Hussain K, Saha P, Alkhadire ZM, Tan SZ, Bailey DM, Williams IM, Bashir M. Endovascular solutions for abdominal aortic aneurysms: A comparative review of clinical outcomes with custom-made endografts. Asian Cardiovasc Thorac Ann 2023; 31:565-576. [PMID: 36299237 DOI: 10.1177/02184923221133956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND The introduction of endovascular aortic repair has revolutionised the treatment of abdominal aortic aneurysms, replacing open surgical repair for the majority of elective cases due to its optimal morbidity and mortality. Several endovascular aortic repair stent grafts exist commercially, one of which is the Fenestrated Anaconda™ by Terumo Aortic which benefits from a very innovative design, unique custom-made approach and highly favourable results. AIMS The main scope of this narrative review is to provide a comprehensive overview of endovascular aortic repair clinical outcomes using the Fenestrated Anaconda™ stent-graft and comparing these with its market competitor, Zenith. This review will also examine the evidence in the literature on the Anaconda™'s custom-made approach. METHODS A comprehensive literature was conducted on several search engines including PubMed, Google Scholar, Ovid, Scopus and Embase to collate the evidence in the literature on clinical outcomes achieved with the Fenestrated Anaconda™ and Zenith including, but not limited to, survival, technical success, target vessel patency, endoleak, reintervention and aneurysm sac regression. RESULTS The Fenestrated Anaconda™ is associated with excellent results, including highly favourable survival, technical and clinical success and target vessel patency rates, very low need for reintervention or conversion, and minimal incidence of complications such as endoleak and endograft migration. The Fenestrated Anaconda™ also drives significant sac regression and aortic remodelling. In addition, its unique custom-made approach enables it to treat highly complex aortic anatomy as well as to 'rescue' failed competitor grafts. CONCLUSION The Fenestrated Anaconda™ has proven that it is a very safe, highly applicable and extremely effective device used for complex aortic and/or iliac pathology based on its novel design and outstanding track record of clinical outcomes.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Kamran Hussain
- East Lancashire Teaching Hospitals NHS Trust, Blackburn, UK
| | - Priyanshu Saha
- School of Medicine, St George's University of London, London, UK
| | | | - Sven Zcp Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education & Improvement Wales (HEIW), Cardiff, UK
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Troisi N, Pulli R, Donato GD, Adami D, Bertagna G, Michelagnoli S, Berchiolli R. Early and Midterm Outcomes of Endovascular Aneurysm Repair With Zenith Alpha Abdominal Stent-Graft: Results From a Multicenter Retrospective Tuscany Registry. J Endovasc Ther 2023:15266028231197151. [PMID: 37646124 DOI: 10.1177/15266028231197151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
PURPOSE Zenith Alpha Abdominal (Cook Medical, Bloomington, IN, USA) is one of the new-generation low-profile stent-grafts with demonstrated satisfactory early and midterm clinical outcomes for endovascular treatment of abdominal aortic aneurysms (AAAs). The aim was to evaluate early and midterm results of this device in the framework of a multicenter regional retrospective registry, with the analysis of morphological factors affecting outcomes, including different limb configurations. MATERIALS AND METHODS Between January 2016 and November 2021, 202 patients with AAA underwent elective endovascular aneurysm repair (EVAR) with implantation of a Zenith Alpha Abdominal in 7 centers. Early (30 day) outcomes in terms of technical and clinical success were assessed. Estimated 5 year outcomes were evaluated in terms of survival, freedom from type I/III endoleak, freedom from surgical conversion, freedom from limb graft occlusion, freedom from any device-related reintervention, and graft infection evaluation by life-table analysis (Kaplan-Meier test). A comparative analysis between different limb configurations (Zenith Spiral Z AAA iliac legs, codes ZISL vs ZSLE) was performed in terms of limb graft occlusion. RESULTS The 30 day technical and clinical success rates were 97.5% and 99.5%, respectively. Median follow-up period was 25.5 months (interquartile range [IQR]: 12-43.25). The 5 year survival rate was 73.6%. The estimated 5 year outcomes in terms of freedom from type I/III endoleak, freedom from surgical conversion, freedom from limb graft occlusion, freedom from any device-related reintervention, and freedom from graft infection were 88.6% (95% CI [confidence interval]: 83.4%-93.1%), 95.8% (95% CI: 92.7%-97.1%), 93.6% (95% CI: 90.2%-96.8%), 87% (95% CI: 83.3%-91.6%), and 97.7% (95% CI: 95.1%-98.9%), respectively. About limb configuration, no differences were found in terms of 5 year freedom from limb graft occlusion (ZSLE 93.4% [95% CI: 89.8%-95.5%] vs ZISL 94.3% [95% CI: 90.1%-95.9%], p=0.342; log-rank 0.903). CONCLUSION Zenith Alpha Abdominal in elective EVAR offered satisfactory early and 5 year outcomes with low complication rates. Limb graft occlusion continued to be an issue. Limb configuration did not affect outcomes. CLINICAL IMPACT The authors describe satisfactory early and 5 year outcomes of Zenith Alpha Abdominal in elective endovascular aortic repair in the framework of a multicenter regional retrospective registry. At 5 years freedom from type I endoleak was 88.6%, and rate of endograft infections and conversions to open repair were very low. in the present study. Hot topic about about Zenith stent-graft still remains the limb graft occlusion with a 30-day overall rate of 2%, and estimated 5-year freedom from limb graft occlusion of 93.6%. Limb graft configuration did not affect limb graft occlusion rate. A standardized protocol including iliac stenting should be adopted to reduce kimb graft occlusion.
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Affiliation(s)
- Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Raffaele Pulli
- CardioThoracic and Vascular Surgery, Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Florence, Italy
| | - Gianmarco de Donato
- Department of Medicine, Surgery, and Neuroscience, Vascular Surgery Unit, University of Siena, Siena, Italy
| | - Daniele Adami
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giulia Bertagna
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Stefano Michelagnoli
- Vascular and Endovascular Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
| | - Raffaella Berchiolli
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Spath P, Pasqui E, Angiletta D, Spinazzola A, Chegai F, Isernia G, Lepidi S, Silingardi R, de Donato G, Gargiulo M. Penumbra Indigo Percutaneous Aspiration Thrombectomy System in the treatment of Aortic Endograft Iliac Limb Occlusion: Results from an Italian Multicentre Registry. Eur J Vasc Endovasc Surg 2023; 66:77-84. [PMID: 37084878 DOI: 10.1016/j.ejvs.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 03/12/2023] [Accepted: 04/12/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVE This study aimed to evaluate the safety and effectiveness of the Penumbra Indigo percutaneous aspiration thrombectomy (PAT) system in the clinical presentation of iliac limb occlusion (ILO) after endovascular aortic repair (EVAR). METHODS A retrospective, observational, multicentre study conducted in eight Italian vascular centres. Consecutive patients presenting with ILO after EVAR were eligible. To assess vessel revascularisation, Thrombo-aspiration In Peripheral Ischaemia (TIPI) classification (score 0-3) was used at presentation (t1), after PAT (t2), and after adjunctive procedures (t3). Successful revascularisation was considered TIPI 2-3 (near complete or complete). Primary intra-operative outcomes were technical success (TS) of Indigo PAT and combined TS of PAT associated with adjunctive procedures when needed. Primary follow up outcomes were safety and effectiveness at one, six, and 12 months. RESULTS From September 2019 to December 2021, there were 48 ILO and 17 patients (35%) [median age 75 years, IQR 71, 83 years; male, 14 (82%); urgent, 8 (47%)] were treated and enrolled. The median time after primary EVAR was 24 months (IQR 0, 42 months). The median clot age from ILO diagnosis to PAT was three days (IQR 1, 12 days). Ten patients (59%) presented with limb threatening ischaemia. At t1, TIPI 0 and 1 was present in 13 (76%) and four (24%) cases, respectively. At t2, primary TS (TIPI 2-3) was achieved in 14 cases (82%) after Indigo PAT (p < .001). Fifteen patients (88%) required adjunctive procedures (14 re-linings, one surgical patch angioplasty). At t3, combined TS was achieved in 16 cases (94%). Intra-operative complication included one (6%) distal embolisation, treated successfully. The 30 day mortality was one case (6%) due to pneumonia. At one, six, and 12 months, clinical success was 100% without ILO recurrence. The median follow up was 23 months (IQR 11, 41 months): at 18 months, survival and freedom from re-intervention were 91 ± 8% and 90 ± 9%, respectively. CONCLUSION This study reports for the first time the efficacy and safety of Penumbra Indigo PAT for ILO after EVAR, with promising technical and clinical success up to one year.
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Affiliation(s)
- Paolo Spath
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy; Department of Vascular Surgery, Hospital "Infermi" Rimini, AUSL Romagna, Rimini, Italy.
| | - Edoardo Pasqui
- Vascular Surgery, University of Siena, DSMCN, Siena, Italy
| | | | - Angelo Spinazzola
- Interventional Radiology, Unit of Radiology, ASST-Crema, Crema, Italy
| | - Fabrizio Chegai
- Vascular and Interventional Radiology, Unit of Radiology, Hospital Viterbo, Viterbo, Italy
| | - Giacomo Isernia
- Department of Vascular and Endovascular Surgery, University of Perugia, Perugia, Italy
| | - Sandro Lepidi
- Department of Vascular Surgery, University Hospital of Trieste, Trieste, Italy
| | - Roberto Silingardi
- Department Vascular Surgery of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Mauro Gargiulo
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy; Bologna Metropolitan Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria S. Orsola, Bologna, Italy
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Chacko P, Hans SS, Nahirniak P, Morton K. Clinical Patterns, Predictors, and Results of Graft Limb Occlusion Following Endovascular Aneurysm Repair. Ann Vasc Surg 2023:S0890-5096(23)00114-0. [PMID: 36918093 DOI: 10.1016/j.avsg.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/02/2023] [Accepted: 02/03/2023] [Indexed: 03/13/2023]
Abstract
OBJECTIVE To assess the incidence, clinical patterns, and outcomes of graft limb occlusion (GLO) following endovascular aneurysm repair (EVAR). METHODS A retrospective study of patients undergoing EVAR from 2002-2017 at two mid-sized suburban teaching hospitals. The ipsilateral and contralateral aorto-common iliac artery angle (A-CIA) and common iliac-external iliac artery angle (CIA-EIA) was determined. The diameter of the EIA, graft extension to the EIA, and prior CIA stenting was recorded. RESULTS Of the 373 patients who underwent EVAR, 319 were analyzed. 22 patients had 23 limbs with GLO (21 unilateral and one bilateral) with a mean follow up of 9.1 +/- 2.1 years. There were no statistically significant differences in mean age, gender, size of the abdominal aortic aneurysm, and risk factors of hypertension, coronary artery disease, diabetes mellitus, and chronic obstructive pulmonary disease in patients with and without GLO. There was no statistically significant difference in A-CIA and CIA-EIA angles. A smaller diameter EIA (6mm or less), graft extension to EIA, and prior CIA stenting were significant predictors of GLO. Four limbs had GLO within one month of EVAR, only open thrombectomy was performed in 2 limbs, open thrombectomy with simultaneous axillo-femoral graft in one limb, and open thrombectomy with self-expandable stent placement in one limb. 12 limbs had GLO within 1-12 months treated with only open thrombectomy in three limbs, open thrombectomy with fasciotomy in one limb, open thrombectomy with graft extension to EIA in one limb, and crossover femoral-femoral graft performed in three limbs. Seven limbs had GLO within 1-5 years with a crossover femoral-femoral graft performed in four limbs and open thrombectomy with graft extension to EIA was performed in one limb. Six limbs with GLO following EVAR did not undergo any intervention. One patient had an above the knee amputation 3 years following occlusion of the axillo-femoral graft and one patient returned in 4 years with an increase in size of the excluded aneurysm leading to acute rupture and death. CONCLUSIONS Graft limb occlusion leads to significant morbidity and mortality following EVAR. Predictors of GLO following EVAR include a small diameter EIA, prior CIA stenting and graft limb extension to the EIA.
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Broda M, Eiberg J, Taudorf M, Resch T. Limb graft occlusion after endovascular aneurysm repair with the Cook Zenith Alpha abdominal graft. J Vasc Surg 2023; 77:770-777.e2. [PMID: 36306934 DOI: 10.1016/j.jvs.2022.10.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Prior reports of the low profile Zenith Alpha abdominal graft (Cook Medical Inc, Bloomington, IN) have shown impaired limb graft patency to be the primary causes of reintervention. Special notices from the manufacturer have indicated certain instructions for use (IFU) violations as the main reasons for these complications. In the present study, we assessed the incidence of limb graft occlusion (LGO) and analyzed the effects of the detailed anatomic risk factors for LGO highlighted in the IFU and previously reported studies. METHODS A retrospective study was performed of 241 patients treated with the low profile Zenith Alpha at a single institution from October 1, 2015 to September 30, 2018. All computed tomography angiograms were analyzed using three-dimensional software. Data were extracted from the electronic medical records until the end of the study period (December 31, 2020). The cumulative incidence of LGO and LGO-related reinterventions were assessed. A regression analysis was performed to evaluate the possible risk factors associated with the development of LGO at specified time points. These included aortic and iliac diameters, graft component oversizing, iliac tortuosity and calcification, overlap of graft components, proximal alignment of ipsilateral and contralateral legs, and sealing zone in the external iliac artery. Reader agreement of iliac calcification and tortuosity was assessed in patients with LGO. RESULTS A total of 33 limbs (7%) in 27 patients (11%) had become occluded. The cumulative incidence of LGO was 7% (95% confidence interval [CI], 5%-9%) per limb up to 3 years postoperatively. The previously described risk factors for LGO were studied using regression analysis; however, no positive association with LGO was identified. Heavily calcified common iliac arteries (CIAs) and external iliac arteries were protective against LGO compared with noncalcified vessels up to 3 years postoperatively (decreased risk, 17% [95% CI, -27% to -7%]; P = .001; and 15% [95% CI, -26 to -5]; P = .005, respectively). The reader agreement of iliac calcification and tortuosity showed substantial agreement (CIA intrareader kappa = 0.75; CIA interreader kappa = 0.62) and almost perfect agreement (intrareader kappa = 0.85; interreader kappa = 0.84), respectively. CONCLUSIONS The cumulative incidence of LGO after endovascular aneurysm repair with the Zenith Alpha graft was 7% per limb up to 3 years postoperatively. None of the analyzed risk factors suggested by the IFUs or current literature were positively associated with LGO.
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Affiliation(s)
- Magdalena Broda
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Jonas Eiberg
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Copenhagen Academy of Medical Education and Simulation, Copenhagen, Denmark
| | - Mikkel Taudorf
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Timothy Resch
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Evaluation of factors associated with limb thrombus formation after endovascular aortic aneurysm repair. J Vasc Surg 2023; 77:440-445. [PMID: 36252827 DOI: 10.1016/j.jvs.2022.10.008] [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: 06/30/2022] [Revised: 10/03/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Limb thrombus formation is a complication that can occur after endovascular aortic repair (EVAR), and its clinical significance has continued to be debated. Our objective was to report the incidence of limb thrombus after EVAR and determine the association of specific demographic, anatomic, and/or graft variables. METHODS A retrospective analysis of EVAR patients at a single tertiary center between January 2010 and December 2018 was performed to determine the limb thrombus rate. Demographic, graft, and anatomic variables were analyzed for an association with limb thrombus. RESULTS A total of 301 patients were included. The average follow-up was 27.6 ± 4.9 months. The mean age was 76.5 ± 0.5 years, and 85% were men. Limb thrombus occurred in 22 patients (7.3%). Of these 22 patients, 11 (50.0%) had had occlusive limb thrombus, 14 (63.6%) were symptomatic, and 17 (77.3%) had required intervention. The patients with limb thrombus were younger (69.8 ± 1.3 years vs 77.1 ± 0.5 years; P < .0001) and more likely to be smokers (10.2% vs 5.2%; P = .10). The incidence of limb thrombus with the Alpha graft (10.7%; Cook Medical Inc, Bloomington, IN) was compared with that with non-Cook grafts (4.0%; P = .07). The average common iliac artery diameter for patients with and without limb thrombus was 14.1 mm and 16.1 mm, respectively (P < .01). Right-sided limb thrombus was more likely in smaller right iliac arteries (14.7 ± 0.9 cm vs 17.0 ± 0.6 cm; P < .05), with a similar finding on the left (13.6 ± 0.9 cm vs 15.2 ± 0.4 cm; P = .13). Unilateral limb thrombus was almost twice as likely on the main body side than on the contralateral side (11 vs 6). Limb thrombus was not associated with aortoiliac disease (odds ratio [OR], 1.31; 95% confidence interval [CI], 0.37-4.62), limb extension (OR, 0.47; 95% CI, 0.06-3.62), or nonmatching limb heights (OR, 1.36; 95% CI, 0.54-3.43). Limb thrombus was also not associated with increased 30-day mortality (P > .05). CONCLUSIONS Limb thrombus formation is a complication that can occur after EVAR (7.3%). In our study, limb thrombus was seen more frequently in younger patients and those who smoked. Cook Alpha grafts had a thrombus formation rate of 10.7%, which was not significantly higher than that with other brands. Limb thrombus was more likely in smaller iliac arteries and on the main body side.
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Karaolanis GI, Hadjis D, Samara E, Gomatos IP, Tzimas P, Glantzounis GK. Low-Profile Altura Endograft System for Endovascular Abdominal Aorta Aneurysm Repair. Preliminary Results in Elective and Emergent Situations. Ann Vasc Surg 2023; 92:188-194. [PMID: 36639096 DOI: 10.1016/j.avsg.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/01/2023] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
BACKGROUND The objective of this study was to assess the Altura endoprosthesis outcomes up to 12 months for patients affected by infrarenal abdominal aortic aneurysms (AAA) either in elective or emergent situations. METHODS This was a single-center retrospective study identifying all patients undergoing endovascular aneurysm repair (EVAR) with the Altura endoprosthesis from January 2021 to August 2022. Outcomes evaluated included mortality, technical and clinical success (freedom from procedure-related death, endoleak, migration, thrombosis, and reintervention), and the freedom from reintervention rate. RESULTS A total of 34 (25 elective and 8 emergent) patients who underwent AAA with Altura endoprosthesis were retrospectively reviewed. The technical success of the Altura endograft either in elective or emergent situations was 100%. There was no inhospital mortality, but 1 (3%) patient who underwent AAA repair emergently, died unexpectedly 7 days after the discharge due to massive pulmonary embolism. The clinical success and the freedom from reintervention during the median follow-up of 12 months (interquartile range [IQR] 12-18), were 97%. One patient presented with disabling intermittent claudication at third month postoperatively, and the computed tomographic angiography (CTA) revealed thrombosis of one of the iliac endografts (3%). The patient underwent femorofemoral bypass with an uneventful postoperative course and immediate relief of the symptoms. One type II endoleak was spontaneously resolved on the sixth month. Sac shrinkage (>3 mm) was registered in 12 patients (35%), but the sac size was stable in the remaining 22 (65%) patients. CONCLUSIONS The preliminary outcomes of the Altura endograft seem to be promising, suggesting that the endograft could be safely used either in elective or emergent situations. Further studies with a major number of participants are needed to document its technical and clinical performance, especially in emergency situations that could be amenable to improvement.
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Affiliation(s)
- Georgios I Karaolanis
- Vascular Unit, Department of Surgery, University Hospital of Ioannina and School of Medicine, Ioannina, Greece.
| | - Demetrios Hadjis
- Vascular Unit, Department of Surgery, University Hospital of Ioannina and School of Medicine, Ioannina, Greece
| | - Evangelia Samara
- Department of Anesthesia and Postoperative Intensive Care, University of Ioannina, Faculty of Medicine, School of Health Sciences, Ioannina, Greece
| | - Ilias P Gomatos
- Kidney Transplantation Unit, Laiko General Hospital of Athens, Athina, Greece
| | - Petros Tzimas
- Department of Anesthesia and Postoperative Intensive Care, University of Ioannina, Faculty of Medicine, School of Health Sciences, Ioannina, Greece
| | - Georgios K Glantzounis
- Department of Surgery, University Hospital of Ioannina and Faculty of Medicine, University of Ioannina, School of Health Sciences, Ioannina, Greece
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Kim J, Chun JY, Ameli-Renani S, Ratnam L, Mailli L, Pavlidis V, Das R, Morgan R. Outcome of endovascular treatment of internal iliac artery aneurysms: a single center retrospective review. CVIR Endovasc 2022; 5:53. [PMID: 36255546 PMCID: PMC9579245 DOI: 10.1186/s42155-022-00330-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/11/2022] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To evaluate the technical feasibility and clinical outcomes of endovascular treatment for internal iliac artery (IIA) aneurysms. MATERIAL AND METHODS This was a retrospective analysis of 25 patients with 32 IIA aneurysms (mean diameter: 39.1 ± 12.6 mm) who underwent endovascular treatment over a 10-year period, and were available for follow-up. Univariate analysis was used to determine the association between variables (including aortoiliac involvement and technique) and outcome. RESULTS The IIA inflow was covered with an iliac stent graft (N = 29) or embolized with a plug (N = 3). The IIA outflow was embolized in all but one case in which there was thrombotic occlusion of outflow branches. Outflow embolization using plugs or coils was performed in the distal IIA or anterior/posterior trunks in 9 cases and distal IIA branches in 22 cases. During a mean follow-up period of 39.9 months, 31.2% of aneurysms demonstrated endoleak and 12.5% demonstrated enlargement. Univariate analysis revealed that endoleak was associated with technical failure (p = 0.01) and that endoleak rate was higher in patients who underwent distal IIA branch embolization (p = 0.03). No variable was associated with sac expansion. Major complication occurred in one patient who died from aneurysm rupture. Minor complications were reported in six patients who developed femoral pseudoaneurysm (N = 2, 8%), buttock claudication (N = 3, 12%), and limb graft occlusion (N = 1, 4%). CONCLUSION Endovascular treatment of IIA aneurysms effectively prevents sac expansion. Endoleak was more frequently observed in cases of technical failure and those in which distal IIA branches were embolized. LEVEL OF EVIDENCE Level 3b, retrospective cohort study.
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Affiliation(s)
- Jinoo Kim
- grid.451349.eDepartment of Radiology, St George’s University Hospitals NHS Foundation Trust, Tooting, London, UK ,grid.411261.10000 0004 0648 1036Department of Radiology, Ajou University Hospital, Suwon, Gyeonggi-do Republic of Korea
| | - Joo-Young Chun
- grid.451349.eDepartment of Radiology, St George’s University Hospitals NHS Foundation Trust, Tooting, London, UK
| | - Seyed Ameli-Renani
- grid.451349.eDepartment of Radiology, St George’s University Hospitals NHS Foundation Trust, Tooting, London, UK
| | - Lakshmi Ratnam
- grid.451349.eDepartment of Radiology, St George’s University Hospitals NHS Foundation Trust, Tooting, London, UK
| | - Leto Mailli
- grid.451349.eDepartment of Radiology, St George’s University Hospitals NHS Foundation Trust, Tooting, London, UK
| | - Vyzantios Pavlidis
- grid.451349.eDepartment of Radiology, St George’s University Hospitals NHS Foundation Trust, Tooting, London, UK
| | - Raj Das
- grid.451349.eDepartment of Radiology, St George’s University Hospitals NHS Foundation Trust, Tooting, London, UK
| | - Robert Morgan
- grid.451349.eDepartment of Radiology, St George’s University Hospitals NHS Foundation Trust, Tooting, London, UK
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Zhou Y, Wang J, Zhao J, Yuan D, Weng C, Wang T, Huang B. The effect of percutaneouS vs. cutdoWn accEss in patients after Endovascular aorTic repair (SWEET): Study protocol for a single-blind, single-center, randomized controlled trial. Front Cardiovasc Med 2022; 9:966251. [PMID: 36061557 PMCID: PMC9437429 DOI: 10.3389/fcvm.2022.966251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/01/2022] [Indexed: 11/30/2022] Open
Abstract
Background Endovascular abdominal aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) have become the first-line treatment for aortic diseases, but current evidence is uncertain regarding whether a percutaneous approach has better outcomes than cutdown access, especially for patient-centered outcomes (PCOs). This study is designed to compare these outcomes of percutaneous access vs. cutdown access after endovascular aortic repair. Method The SWEET study is a randomized, controlled, single-blind, single-center non-inferiority trial with two parallel groups in two cohorts respectively. After eligibility screening, subjects who meet the inclusion criteria will be divided into Cohort EVAR or Cohort TEVAR according to clinic interviews. And then participants in two cohorts will be randomly allocated to either intervention groups receiving percutaneous access endovascular repair or controlled groups receiving cutdown access endovascular repair separately. Primary clinician-reported outcome (ClinRO) is access-related complication, and primary patient-centered outcome (PCO) is time back to normal life. Follow-up will be conducted at 2 weeks, 1 month, 3 months postoperatively. Discussion The choice of either percutaneous or cutdown access may not greatly affect the success of EVAR or TEVAR procedures, but can influence the quality of life and patient-centered experience. Given the very low evidence for ClinROs and few data for PCOs, comparison of the percutaneous vs. cutdown access EVAR and TEVAR is essential for both patient-centered care and clinical decision making in endovascular aortic repair. Trial registration Chinese Clinical Trial Registry ChiCTR2100053161 (registered on 13th November, 2021).
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Affiliation(s)
- Yuhang Zhou
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jiarong Wang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chengxin Weng
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Tiehao Wang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Tiehao Wang
| | - Bin Huang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
- Bin Huang
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Jubouri M, Surkhi AO, Tan SZCP, Bailey DM, Williams IM, Bashir M. Abdominal Aortic Aneurysm: Can the Anaconda™ Custom-Made Device Deliver? An International Perspective. Front Cardiovasc Med 2022; 9:959149. [PMID: 35911560 PMCID: PMC9329582 DOI: 10.3389/fcvm.2022.959149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/20/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Since the introduction of endovascular aortic repair (EVAR), it has demonstrated excellent clinical outcomes and has replaced open surgical repair (OSR) in the treatment of abdominal aortic aneurysms (AAA). AAA is a life-threatening abnormal dilation of the abdominal aorta to 1.5 times its normal diameter. Several commercial EVAR devices exist on the global market, with the Terumo Aortic Fenestrated Anaconda™ graft showing superiority. In this study, we sought to provide an international perspective using multicenter-multinational data on the Anaconda™ device characteristics, design, and delivery, and discuss relevant literature. Materials and Methods This study represents a cross-sectional international analysis of custom-made fenestrated Anaconda™ device. Ethical and legal approval for data collection was obtained from each of the local authorities. For the statistical analysis, SPSS 28 for Windows and R were utilized. Pearson’s chi-square analysis was used to assess differences in cumulative distribution frequencies between select variables. Statistical significance for all two-tailed tests was set at p < 0.05. Results A total of 5,030 Anaconda™ devices were implanted during the 9-year study period in 27 countries spanning 6 continents. The predominant device category was bifurcate (83.6%), whereas the most common proximal ring stent configuration being standard (64.5%). All devices were delivered within 8 weeks of diagnosis, with most being implanted within 6–8 weeks (55.4%). The Anaconda™ was indicated in the 3,891 (77.4%) patients due to competitor rejection/inability to treat unsuitable/complex aortic anatomy. In the remaining 1,139 (22.6%) patients, it was utilized based on surgeon preference. Almost all devices (95%) were delivered along with a prototype. Of the total 5,030 Anaconda™ devices, 438 (8.7%) used 0–1 fenestrations, 2,349 (46.7%) used 2–3, while 2,243 (44.6%) utilized 4, 5, or 6 fenestrations. Discussion The Terumo Aortic Fenestrated Anaconda™ device features a highly unique and innovative design that enables it to treat highly complex aortic anatomy while achieving excellent results. The Anaconda™’s custom-made approach allows it to be tailored to individual patient anatomy, in addition to the device prototype provided by Terumo Aortic optimize clinical outcomes. Finally, the fenestrated Anaconda™ is a highly versatile device offering a wide range of device categories, configurations, and sizes.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, United Kingdom
| | | | - Sven Z. C. P. Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Damian M. Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Cardiff, United Kingdom
| | - Ian M. Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Cardiff, United Kingdom
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales (HEIW), Cardiff, United Kingdom
- *Correspondence: Mohamad Bashir,
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Chait J, Mendes BC, DeMartino RR. Anatomic factors to guide patient selection for fenestrated-branched endovascular aortic repair. Semin Vasc Surg 2022; 35:259-279. [DOI: 10.1053/j.semvascsurg.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 11/11/2022]
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Midterm outcomes of aneurysm repair with the COOK Zenith Alpha abdominal endovascular graft. J Vasc Surg 2022; 76:942-950.e1. [PMID: 35367569 DOI: 10.1016/j.jvs.2022.03.862] [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: 12/09/2021] [Accepted: 03/16/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Outcome reports after endovascular aneurysm repair (EVAR) using the low-profile Zenith Alpha Abdominal Endovascular grafts (COOK medical, Bjæverskov, Denmark) are sparse. We present results from a single-center cohort treated with the Zenith Alpha, from a period where the graft was the primary EVAR device choice. The aim of the study was to evaluate short- and midterm outcomes of patients treated with the Zenith Alpha. METHODS A retrospective single-center study was performed including all patients treated with the Zenith Alpha graft from October 1, 2015, to September 30, 2018. All patients underwent computed tomography angiography (CTA) imaging preoperatively as well as at three and 12 months postoperatively. Hereafter, patients were followed yearly with duplex ultrasound and clinical exams. Additional imaging was performed on indication. All CTAs were analyzed using three-dimensional reconstruction software (Aquarius, TeraRecon, Durham, NC, USA). Data was extracted from electronic charts according to a protocol that remained unchanged until the end of the study (December 31, 2020). The following outcomes were assessed according to SVS/ISCVS reporting criteria: aortic-related and all-cause mortality, re-interventions, instruction for use (IFU) violations, endoleaks (EL), and aneurysm shrinkage. RESULTS A total of 241 patients were treated with the Zenith Alpha, and 214 (89%) were asymptomatic repairs. Technical success was achieved in 238 (99%) patients. 157 (65%) patients received implantation outside IFU. The median hospital length of stay was two days [IQR 2-3 days]. The median clinical follow-up was 35.1 months [IQR 28.8-47.5 months]. The four-year Kaplan-Meier (KM) estimate of freedom from re-intervention was 66% (95% CI: 59-73). The main reasons for re-interventions were iliac limb stenosis and occlusion (n=30; 12%) and type 2 EL (n=13; 5%). Overall, significantly more patients with grafts implanted outside distal IFU developed type 1B ELs (T1BELs) (n=10/11; p=.009). Aneurysm sac shrinkage was observed in 48 (25%) patients one year postoperatively. KM estimates of freedom from aortic-related mortality was 99% (95% CI: 98-100) four years postoperatively. CONCLUSIONS EVAR with the Zenith Alpha shows acceptable freedom from aortic-related mortality up to four years postoperatively. The majority of patients were treated outside IFU, and significantly more T1BEL appeared in this subgroup of patients. The leading cause for re-intervention was impaired limb patency. The root cause for impaired limb patency requires further investigation.
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Fujimura N, Ichihashi S, Obara H, Asakura T, Komooka M, Onitsuka S, Kurimoto Y, Kato H, Ohki T. Early Clinical Outcomes of Initial Launch of the Zenith Alpha Abdominal Endovascular Graft in Japan. J Endovasc Ther 2022; 30:241-249. [PMID: 35249411 DOI: 10.1177/15266028221079772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: This study retrospectively evaluated the 12-month outcomes of the Zenith Alpha Abdominal Endovascular graft (Zenith Alpha AAA, Cook, Inc, Bloomington, Indiana), which was launched partially in Japan in March 2019, starting with 9 selected sites. Methods: A retrospective analysis was performed of all endovascular aneurysm repairs (EVAR) for abdominal aortic aneurysms using the Zenith Alpha AAA. Late complications were defined as any aneurysm-related events occurring >30 days after EVAR, including an aneurysm sac enlargement of >5 mm and any reinterventions performed. Endoleaks without sac enlargement or reinterventions were excluded from late complications. Results: During the study period, 79 EVARs using the Zenith Alpha AAA were performed. The mean age was 76.6±6.9 years old, 91.1% of patients were male, and the mean aneurysm diameter was 51.1±7.5 mm. Instructions for use violation was observed in 27 patients (34.2%), most frequently being a severely angulated proximal neck (>60°). There were 4 intraoperative complications, including 2 unintentional partial renal artery coverages caused by the premature anchoring of the exposed suprarenal stent barb to the aortic wall, which was a result of the design change of the top cap deletion. Since it was a partial coverage without flow impairment and since renal stenting was unsuccessful, it was left untreated and had no subsequent renal function impairment. During the mean follow-up of 444±123 days, 74 patients completed 12 months of follow-up. Freedom from late complications at 12 months was 90.8%, which included 2 limb occlusions (2.5%). Of 71 patients with a 12-month computed tomography scan, there was only 1 type 1a endoleak (1.3%), 1 sac enlargement of >5 mm (1.3%), and an aneurysm sac shrinkage of >5 mm was observed in 42.2% of patients. There was no type 3 endoleak during the follow-up. Conclusions: This study demonstrated that the new generation of low-profile Zenith Alpha AAA has satisfactory early clinical outcomes, comparable to those obtained with the conventional Zenith endovascular graft. Long-term follow-up is needed to determine whether these favorable outcomes persist.
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Affiliation(s)
- Naoki Fujimura
- Department of Vascular Surgery, Saiseikai Central Hospital, Tokyo, Japan
| | - Shigeo Ichihashi
- Department of Radiology, Nara Medical University, Kashihara, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Toshihisa Asakura
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Masatoshi Komooka
- Department of Cardiovascular Surgery, Yao Tokushukai Hospital, Osaka, Japan
| | - Seiji Onitsuka
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Yoshihiko Kurimoto
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
| | - Hiroaki Kato
- Department of Radiology, Mie University Hospital, Tsu, Japan
| | - Takao Ohki
- Department of Vascular Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Roush WP, Behrens M, Smith JB, Kruse RL, Balasundaram N, Vogel TR, Bath J. Outcomes of Elective Abdominal Aortic Aneurysm Repair in the Setting of Malignancy. J Vasc Surg 2022; 76:428-436. [DOI: 10.1016/j.jvs.2022.01.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/30/2022] [Indexed: 12/26/2022]
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Leeuwerke SJG, de Niet A, Geelkerken RH, Reijnen MMPJ, Zeebregts CJ. Incidence and predictive factors for endograft limb patency of the Fenestrated Anaconda™ endograft used for complex endovascular aneurysm repair. J Vasc Surg 2021; 75:1512-1520.e1. [PMID: 34921964 DOI: 10.1016/j.jvs.2021.11.066] [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: 06/12/2021] [Accepted: 11/12/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the incidence, risk factors and outcomes of treatment for limb occlusion in patients treated for complex (thoraco-)abdominal aortic aneurysms (AAA) with the Fenestrated Anaconda™. METHODS Between June 2010 and May 2018, 335 patients underwent elective fenestrated aortic aneurysm repair in 11 participating centers using the Fenestrated Anaconda™ with a median follow-up of 14.3 months (IQR 27.4). The primary outcome measure was freedom-from-limb-occlusion. Secondary outcome measures were freedom-from-limb-related-reintervention, secondary patency, and risk factors associated with limb occlusion. RESULTS Thirty (9.0%) patients presented with limb occlusion during follow-up with freedom-from-limb-occlusion of 98.5%, 91.2%, and 81.7% at 30-days, 1 and 5 years, respectively. In 87% of cases, no obvious cause for limb occlusion was documented. Primary occlusion occurred within 30-days in 36.7% and within 1 year in 80.0%. Twenty-three (6.9%) patients underwent an occlusion-related reintervention; seven (23.3%) patients were treated conservatively. Freedom-from-limb-occlusion-related-reintervention at 30-days, one and five years was 97.8%, 93.2% and 88.6%, respectively. Secondary patency was 91.3% after 1-month and 86.2% after 1 and 5 years, respectively. Female sex (OR 3.27 - 95% CI 1.28 to 8.34, P = .01) was a statistically significant predictor for limb occlusion. A higher percentage of thrombus in the aneurysm sac appeared to be protective for limb occlusion (0% compared to <25%: OR 0.22 - 95% CI 0.07 to 0.63, P = .01; 0% compared to 25-50%: OR 0.20 - 95% CI 0.07 to 0.57, P = .00 and 0% compared to >50%: OR 0.08 - 95% CI 0.02 to 0.38, P = .00), as did iliac angulation (OR 0.99 - 95% CI 0.98 to 1.00, P = .04). CONCLUSION Limb occlusion remains a significant impediment of endograft durability in patients treated with the Fenestrated Anaconda™, especially in female patients. Controversially, a high aneurysmal thrombus load and a high degree of iliac angulation appeared to be protective for limb occlusion, for which no obvious cause could be identified.
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Affiliation(s)
- S J G Leeuwerke
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - A de Niet
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - R H Geelkerken
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands; Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - M M P J Reijnen
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands; Department of Surgery, Rijnstate, Arnhem, the Netherlands
| | - C J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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