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Chun JY, de Haan M, Maleux G, Osman A, Cannavale A, Morgan R. CIRSE Standards of Practice on Management of Endoleaks Following Endovascular Aneurysm Repair. Cardiovasc Intervent Radiol 2024; 47:161-176. [PMID: 38216742 PMCID: PMC10844414 DOI: 10.1007/s00270-023-03629-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/19/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Endoleaks represent the most common complication after EVAR. Some types are associated with ongoing risk of aneurysm rupture and necessitate long-term surveillance and secondary interventions. PURPOSE This document, as with all CIRSE Standards of Practice documents, will recommend a reasonable approach to best practices of managing endoleaks. This will include imaging diagnosis, surveillance, indications for intervention, endovascular treatments and their outcomes. Our purpose is to provide recommendations based on up-to-date evidence, updating the guidelines previously published on this topic in 2013. METHODS The writing group was established by the CIRSE Standards of Practice Committee and consisted of clinicians with internationally recognised expertise in endoleak management. The writing group reviewed the existing literature performing a pragmatic evidence search using PubMed to select publications in English and relating to human subjects up to 2023. The final recommendations were formulated through consensus. RESULTS Endoleaks may compromise durability of the aortic repair, and long-term imaging surveillance is necessary for early detection and correct classification to guide potential re-intervention. The majority of endoleaks that require treatment can be managed using endovascular techniques. This Standards of Practice document provides up-to-date recommendations for the safe management of endoleaks.
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Affiliation(s)
- Joo-Young Chun
- St George's University Hospitals NHS Foundation Trust, London, UK.
- St George's University of London, London, UK.
| | - Michiel de Haan
- Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Asaad Osman
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Robert Morgan
- St George's University Hospitals NHS Foundation Trust, London, UK
- St George's University of London, London, UK
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Fu H, Shen QR, Zhao Y, Ni M, Zhou CC, Chen JK, Chi C, Li DJ, Liang G, Shen FM. Activating α7nAChR ameliorates abdominal aortic aneurysm through inhibiting pyroptosis mediated by NLRP3 inflammasome. Acta Pharmacol Sin 2022; 43:2585-2595. [PMID: 35217818 PMCID: PMC9525652 DOI: 10.1038/s41401-022-00876-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/20/2022] [Indexed: 12/16/2022] Open
Abstract
Abdominal aortic aneurysm (AAA) is defined as a dilated aorta in diameter at least 1.5 times of a normal aorta. Our previous studies found that activating α7 nicotinic acetylcholine receptor (α7nAChR) had a protective effect on vascular injury. This work was to investigate whether activating α7nAChR could influence AAA formation and explore its mechanisms. AAA models were established by angiotensin II (Ang II) infusion in ApoE-/- mice or in wild type and α7nAChR-/- mice. In vitro mouse aortic smooth muscle (MOVAS) cells were treated with tumor necrosis factor-α (TNF-α). PNU-282987 was chosen to activate α7nAChR. We found that cell pyroptosis effector GSDMD and NLRP3 inflammasome were activated in abdominal aorta, and inflammatory cytokines in serum were elevated in AAA models of ApoE-/- mice. Activating α7nAChR reduced maximal aortic diameters, preserved elastin integrity and decreased inflammatory responses in ApoE-/- mice with Ang II infusion. While α7nAChR-/- mice led to aggravated aortic injury and increased inflammatory cytokines with Ang II infusion when compared with wild type. Moreover, activating α7nAChR inhibited NLRP3/caspase-1/GSDMD pathway in AAA model of ApoE-/- mice, while α7nAChR deficiency promoted this pathway. In vitro, N-acetylcysteine (NAC) inhibited NLRP3 inflammasome activation and NLRP3 knockdown reduced GSDMD expression, in MOVAS cells treated with TNF-α. Furthermore, activating α7nAChR inhibited oxidative stress, reduced NLRP3/GSDMD expression, and decreased cell pyroptosis in MOVAS cells with TNF-α. In conclusion, our study found that activating α7nAChR retarded AAA through inhibiting pyroptosis mediated by NLRP3 inflammasome. These suggested that α7nAChR would be a potential pharmacological target for AAA.
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Affiliation(s)
- Hui Fu
- Department of Pharmacy, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Qi-Rui Shen
- Chemical Biology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, China
| | - Yi Zhao
- Department of Pharmacy, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Min Ni
- Department of Pharmacy, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Can-Can Zhou
- Department of Pharmacy, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Ji-Kuai Chen
- Department of Health Toxicology, Faculty of Naval Medicine, Second Military Medical University/Naval Medical University, Shanghai, 200433, China
| | - Chen Chi
- Department of Pharmacy, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Dong-Jie Li
- Department of Pharmacy, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
- Institute of Nuclear Medicine, Tongji University School of Medicine, Shanghai, 200092, China
| | - Guang Liang
- Chemical Biology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, China.
| | - Fu-Ming Shen
- Department of Pharmacy, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.
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Kemmling S, Wiedner M, Stahlberg E, Sieren M, Jacob F, Barkhausen J, Goltz JP. Five-year outcomes of the Bi- versus Trimodular EndurantTM stent-graft in 100 patients with infrarenal abdominal aortic repair. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:308-316. [PMID: 35343657 DOI: 10.23736/s0021-9509.22.11947-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Recent studies on the Endurant™ endografts mainly compared outcomes of the bimodular stent-graft to other manufacturer's endografts or reported results for cases outside manufacturer's instructions for use (IFU), while data on the experience of standard endovascular aortic repair (EVAR) of infrarenal abdominal aortic aneurysms (AAA) inside manufacturer's IFU comparing the bi- with the trimodular device is limited. METHODS Inclusion criteria were: 1) infrarenal aneurysms (>50 mm diameter) treated by EndurantTM II (END II) or EndurantTM IIs (END IIs) stent-graft inside manufacturer's IFU; 2) available CTA with 1 mm reconstruction of the entire aorta prior to intervention. Endpoints comparing the devices included technical success, 30-day mortality, rate of complications (bleeding with conversion to open repair, stent-graft stenosis/occlusion, acute distal embolism, infection or postprocedural necessity of dialysis), endoleaks and reinterventions (5-year follow-up). Aneurysm sac diameters were compared between baseline preinterventional CTA and last post-interventional CTA. RESULTS One hundred patients (90% male, mean age 74 years) treated with END II (N.=66) or END IIs (N.=34) were included. Technical success was 99%. One procedure-related active bleeding occurred ending up in surgical conversion (END II N.=1). 30d mortality was 0%. No initial type I/III endoleaks were present. Re-interventions were required in 19/100 (19%) of patients (END II N.=10; END IIs N.=9, P=0.17). The outcome of EVAR including technical success, 30d mortality, rate of complications, endoleaks and re-interventions showed no significant differences comparing END II/IIs. CONCLUSIONS Five-year outcomes of EVAR show consistently safe and effective results for either END II or IIs device.
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Affiliation(s)
- Susanne Kemmling
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig Holstein, Lübeck, Germany -
| | - Marcus Wiedner
- Department for Surgery, University Hospital of Schleswig Holstein, Lübeck, Germany
| | - Erik Stahlberg
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig Holstein, Lübeck, Germany
| | - Malte Sieren
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig Holstein, Lübeck, Germany
| | - Fabian Jacob
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig Holstein, Lübeck, Germany
| | - Joerg Barkhausen
- Department for Radiology and Nuclear Medicine, University Hospital of Schleswig Holstein, Lübeck, Germany
| | - Jan P Goltz
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, SANA Clinic, Lübeck, Germany
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Zhao X, Liu Y, Sun M, Wang Y. Efficacy of contrast-enhanced ultrasound in detection of type II endoleak after abdominal aortic aneurysm surgery: A prospective cohort study. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:474-479. [PMID: 35238044 DOI: 10.1002/jcu.23166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 12/07/2021] [Accepted: 01/18/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE This study aimed to evaluate the efficacy of conventional contrast-enhanced ultrasound (CEUS) in detection of type II endoleak after endovascular abdominal aortic aneurysm repair (EVAR). METHODS From January 2015 to April 2018, 205 patients underwent EVAR were included. CEUS and computed tomography angiography (CTA) were performed at 1-month follow-up postoperatively to detect type II endoleak. CEUS was performed at 3- and 6-month follow-up to evaluate the development of type II endoleak. The diameter extension of type II endoleak increased greater than 5 mm was defined as enlarge group, and that increased less than 5 mm was defined as stable group. The difference of arrival time (AT) of contrast agent, maximum cross-sectional area (MCSA) of contrast agent and the blood flow velocity (BFV) of the abnormal blood around the stent graft were compared. RESULTS At 1-month after EVAR, 65 cases of endoleak were detected by CEUS, including 25 cases of type I, 30 cases of type II endoleak and 10 cases of type III endoleak. Among them, 50 cases were also detected by CTA. The diameter extension of 12 cases of type II endoleak increased greater than 5 mm, and that of eight cases increased less than 5 mm. The average AT of the enlarge group was significantly shorter than that of the stable group, while the MCSA of contrast agent and the BFV were significantly higher than that of the stable group (p < 0.05). CONCLUSION CEUS has predictive value for the natural outcome of type II endoleak.
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Affiliation(s)
- Xiaoning Zhao
- Department of Ultrasound, Beijing-Shijitan Hospital, Beijing, China
| | - Yong Liu
- Department of Ultrasound, Beijing-Shijitan Hospital, Beijing, China
| | - Mingyan Sun
- Ninth Health Division, The Second Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yingying Wang
- Department of Ultrasound, Beijing-Shijitan Hospital, Beijing, China
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Castelli MA, Pfund G, Auza D, Battú C, Balestrini J, De Luca I, Zaefferer P. Predictors of type IIIa endoleak after Endovascular Aortic Repair with anatomic fixation endografts. J Vasc Surg 2021; 75:1583-1590.e1. [PMID: 34788651 DOI: 10.1016/j.jvs.2021.10.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Concern regarding the use of anatomic fixation endografts was raised as previous data suggested increased risk of late device uncoupling and type IIIa endoleak in this setting. Some risk factors have been identified as predictors of graft failure. We aim to determine if increase in aortic tortuosity index over the time is associated with increased risk of type IIIa endoleak. METHODS We conducted a single center retrospective cohort study of patients treated with endovascular repair of infrarenal abdominal aortic aneurysms with the Endologix platform. Patients with at least two postoperative CT scans were included in the analysis. Aortic tortuosity index was determined in the first and last available CT scan to determine any change. Multivariate analysis was performed in order to detect risk predictors of type IIIa endoleak occurrence. RESULTS A total of 173 patients were included in the analysis. 21 patients (12.1%) presented type IIIa endoleak. Cumulative freedom from type IIIa endoleak determined by Kaplan-Meier method was 99.4%, 92.5%, 86.1% and 83.3% at 1, 3, 5 and 8 years respectively. Time dependent optimal cutoff values of 0.03 for aortic tortuosity index increase and 15 mm for decrease in modules overlapping over time were obtained with Contal and O'Quigley method to predict type IIIa endoleak. After dichotomizing data around these critical values, a Cox proportional hazards model was obtained to predict type IIIa endoleak occurrence. Maximum preoperative AAA diameter (OR 1.09), smoking (OR 26.67), initial device components overlap (OR 0.91), aortic tortuosity index increase >0.03 (OR 4.56) and decrease in device components overlap > 15 mm (OR 6.13) were associated with type IIIa endoleak occurrence. CONCLUSIONS Aortic tortuosity index increase, device components overlap decrease, maximum preoperative aortic diameter, tobacco use and initial device components overlap were predictive of type IIIa endoleak occurrence. Close follow up with CT scan with aortic tortuosity index and device components overlap measure is warranted in these patients and prompt repair seems justified when any of these risk factors is present.
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Affiliation(s)
- Mariano A Castelli
- Department of Vascular and Endovascular Surgery, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina.
| | - Guillermo Pfund
- Department of Vascular and Endovascular Surgery, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Delfina Auza
- Department of Vascular and Endovascular Surgery, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Camila Battú
- Department of Vascular and Endovascular Surgery, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Julián Balestrini
- Department of Vascular and Endovascular Surgery, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Ignacio De Luca
- Department of Vascular and Endovascular Surgery, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Patricio Zaefferer
- Department of Vascular and Endovascular Surgery, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
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Quaglino S, Mortola L, Ferrero E, Ferri M, Cirillo S, Lario CV, Negro G, Ricotti A, Gaggiano A. Long-term failure after endovascular aneurysm sealing in a real-life, single-center experience with the Nellix endograft. J Vasc Surg 2020; 73:1958-1965.e1. [PMID: 33278539 DOI: 10.1016/j.jvs.2020.11.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Endovascular aneurysm sealing (EVAS) is an innovative alternative to conventional endovascular aneurysm repair (EVAR). EVAS relies on sac anchoring without proximal fixation to achieve sealing and should have allowed for the treatment of a broader range of anatomic features compared with standard EVAR. Despite the encouraging early reports, the mid- and long-term follow-up data have shown increased rates of failure. To address the issue, the manufacturer introduced revised instructions for use (IFU) in 2016. The present study reports the outcomes of this system after a median follow-up of 45 months. METHODS Data for all patients electively treated with EVAS at our institution were retrospectively collected. The patients were retrospectively reclassified according to the 2016 revised IFU of the device. All patients in the present series had undergone EVAS for the treatment of infrarenal abdominal aortic aneurysms (AAAs). The primary end point was therapeutic failure: graft migration >5 mm, sac expansion >5 mm, type IA endoleak (Is2 and Is3 using the Van den Ham classification), type Ib endoleak, and secondary rupture. The overall mortality, aortic-related mortality, and reintervention rates were also analyzed. RESULTS A total of 101 patients had undergone elective treatment by EVAS from 2013 to 2018 for infrarenal AAAs. The median follow-up was 3.75 years. Therapeutic failure was observed in 31 of the 101 patients (30.7%), with no significant difference between the in-IFU and off-IFU 2016 subgroups. Failure occurred at a median interval of 34 months from the index procedure. Of the 101 patients, 6.9% had presented with secondary rupture. Freedom from aneurysm-related mortality was 96.9% at 1 and 2 years and 89.9% at 5 years. Freedom from reintervention decreased over time: 94.7% at 1 year, 77% at 4 years, and 52.1% at 6 years. Of the 101 patients, 14 (13.9%) had undergone emergent or elective graft explantation. CONCLUSIONS EVAS performed worse than conventional endografts for several critical end points, regardless of any preoperative anatomic parameters. The incidence of therapeutic failures tended to increase over time, especially 4 years after the index procedure.
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Affiliation(s)
- Simone Quaglino
- Vascular and Endovascular Surgery Unit, Umberto I Mauriziano Hospital, Turin, Italy.
| | - Lorenzo Mortola
- Vascular and Endovascular Surgery Unit, University Hospital of Novara, Novara, Italy
| | - Emanuele Ferrero
- Vascular and Endovascular Surgery Unit, Umberto I Mauriziano Hospital, Turin, Italy
| | - Michelangelo Ferri
- Vascular and Endovascular Surgery Unit, Umberto I Mauriziano Hospital, Turin, Italy
| | | | | | | | - Andrea Ricotti
- Department of Public Health Sciences, School of Health Statistics and Biometry, University of Turin, Turin, Italy
| | - Andrea Gaggiano
- Vascular and Endovascular Surgery Unit, Umberto I Mauriziano Hospital, Turin, Italy
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Gaffey AC, Damrauer SM. Evolving Concepts, Management, and Treatment of Type 1 Endoleaks after Endovascular Aneurysm Repair. Semin Intervent Radiol 2020; 37:395-404. [PMID: 33041486 DOI: 10.1055/s-0040-1715883] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Over the past 20 years, there has been tremendous progress in endovascular aneurysm repair techniques and devices. The application of new third- and fourth-generation devices (from 2003 onward) has led to changes in the incidence and management of endoleaks. This comprehensive review aims to outline the most recent concepts with respect to pathophysiology/risk factors and management of Type 1 endoleaks.
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Affiliation(s)
- Ann C Gaffey
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Perlman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott M Damrauer
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Perlman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Cannavale A, Lucatelli P, Corona M, Nardis P, Basilico F, De Rubeis G, Santoni M, Catalano C, Bezzi M. Evolving concepts and management of endoleaks after endovascular aneurysm repair: where do we stand in 2019? Clin Radiol 2019; 75:169-178. [PMID: 31810539 DOI: 10.1016/j.crad.2019.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 10/31/2019] [Indexed: 11/27/2022]
Abstract
In recent years, there has been tremendous progress in endovascular aneurysm repair (EVAR) techniques and devices. This process has seen a change in incidence, risk factors, and treatment of endoleaks as well as in follow-up protocols after EVAR. In particular, recent literature has highlighted new concepts in the evaluation and prevention/treatment of type I and II endoleak after standard EVAR. There is also recent evidence regarding new imaging protocols for follow-up after EVAR, which include magnetic resonance imaging and contrast-enhanced ultrasound. This comprehensive review aims to outline the most recent concepts on imaging follow-up, pathophysiology/risk factors, and management of endoleaks.
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Affiliation(s)
- A Cannavale
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy.
| | - P Lucatelli
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - M Corona
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - P Nardis
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - F Basilico
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - G De Rubeis
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - M Santoni
- Department of Radiological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - C Catalano
- Department of Radiological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - M Bezzi
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
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