TREO Aortic Endograft Demonstrates Significant Aneurysmal Sac Shrinkage

TREO Aortic Endograft Demonstrates Superior Aneurysmal Sac Regression Over Mid-Term Follow-up

INTRODUCTION

Aneurysmal sac regression is a predictor of long-term outcomes after endovascular aneurysm repair (EVAR). This study aimed to compare a large cohort of TREO and non-TREO endografts over a mid-term follow-up and compare abdominal aortic aneurysm sac regression. The hypothesis was that TREO endografts have an increased sac regression by 24 mo.

METHODS

This is a retrospective analysis of all EVARs completed at a single institution between 2015 and 2024. Clinical and imaging data were collected from an institutional database and patients' records. The analysis included all TREO and age, sex, anticoagulation use and current smoking-matched non-TREO endografts that satisfied anatomic indications for use of the TREO graft. The primary outcomes were sac regression at 12 and 24 mo, and secondary outcomes were rates of mortality, endoleak, and reintervention.

RESULTS

Twenty-one TREO grafts were matched to 68 non-TREO grafts. The groups were similar in demographics, comorbidities, and preoperative anatomy. Preoperative abdominal aortic aneurysm sac size was larger in the TREO cohort. The mean reduction in sac size in mm was greater in the TREO cohort compared to the non-TREO cohort (-12.6 ± 8.95 versus -7.83 ± 7.74 mm, P = 0.039) over the study period. Cox regression analysis identified the TREO stent graft to be associated with 1-y sac regression (hazard ratio = 2.42, P = 0.019). The incidence of all-cause endoleaks, reintervention, and mortality were similar between cohorts.

CONCLUSIONS

These findings suggest that the TREO endograft offers better mid-term outcomes with respect to sac regression with no differences in the incidence of endoleak, mortality, or reintervention.

Stability of the aneurysmatic sac post-EVAR could no longer be a reliable criterion of healing

BACKGROUND

Evaluation of the impact of aneurysm sac behavior in terms of either stability or shrinkage after endovascular aneurysm repair (EVAR) on long-term clinical outcomes.

METHODS

A retrospective study was conducted on 1483 consecutive patients who underwent EVAR from 1999 to 2021 at our institution. 1037 patients met inclusion criteria (1037/1483, 69.9%): abdominal aortic or aorto-iliac aneurysm, elective surgery, follow-up (FU) ≥12 months. Patients who had sac stability (330/1037, 31.8%) and patients who demonstrated sac shrinkage (542/1037, 52.2%) at FU were compared; patients who presented sac increase at FU were excluded (165/1037, 16%).

PRIMARY ENDPOINTS

rupture rates, need for surgical conversion, and long-term aneurysm-related mortality. Secondary endpoints: all type endoleak rates and long-term reintervention rates.

RESULTS

Mean FU was 61.2 months (IQ 26-85.7 months). In terms of comorbidities, the group of patients with stable sac showed greater association with polidistrectual atherosclerotic manifestations. Estimated 12-year survival was 42.9% in the stable sac group and 65% in the shrinked group (P<0.001), although there were no significant differences in terms of freedom from aneurysm-related death (97.3% vs. 95.4% estimated at 12 years, P=0.493). Patients with sac stability had higher rates of rupture (2.1% vs. 0.6%, P=0.035) and surgical conversion (2.1% vs. 0.6%, P=0.035). The stable sac group had significantly higher rates of all type endoleak during FU (45.8% vs. 24%, P<0.001). Estimated 12-year freedom from reintervention rates were 56.2% and 83.9% respectively (P<0.001).

CONCLUSIONS

After more than 20 years of EVAR experience it is probably time to reconsider the procedure clinical success parameters as a patient with a stable sac cannot be considered healed.

The Association between Device Instructions for Use Adherence and Outcomes after Elective Endovascular Aortic Abdominal Aneurysm Repair

OBJECTIVE

Aortic neck anatomy has a significant impact on the complexity of endovascular aortic aneurysm repair (EVAR), with concern that neck characteristics outside of instructions for use (IFU) may result in worse outcomes. Therefore, this study determined the impact of neck characteristics outside of IFU on perioperative and one-year outcomes and mid-term survival after EVAR.

METHODS

We identified all patients undergoing elective infrarenal EVAR from December 2014 to May 2020 in the Vascular Quality Initiative database. Neck characteristics outside of IFU were determined based the specific device IFU neck characteristics (Neck diameter, length, and angulation). Patients without one-year follow-up were excluded for the 1-year outcomes analyses (n=6,138 (40%)). We used multivariable adjusted logistic regression and Cox proportional hazard models to identify the independent associations between neck characteristics outside of IFU and our outcomes.

RESULTS

Of the 15,448 patients identified, 22.1% had neck characteristics outside of IFU, including 6.6% with a infrarenal angle, 6.8% with a neck length, 10.4% with a neck diameter, and 1.1% with a suprarenal angulation outside of IFU. Of these, 2.4% had more than one neck characteristic outside of IFU. Patients with neck characteristics outside of IFU were more often female (27.9% vs. 15.0%, P<.001) and were older (median age 75 vs. 73, P<.001). EVAR patients with neck characteristics outside of IFU had higher rates of type Ia endoleaks at completion (4.8% vs. 2.5%, P<.001), perioperative mortality (1.2% vs. 0.6%, P<.001), one-year sac expansion (7.1% vs. 5.3%, P=.017), and one-year reinterventions (4.4% vs. 3.2%, P=.03). In multivariable adjusted analyses, neck characteristics outside of IFU were independently associated with type Ia completion endoleaks (OR 1.6, [1.3-2.0], P<.001), perioperative mortality (OR 1.8; [1.2-2.7]; P=.005), one-year sac expansion (OR 1.4; [1.0-1.8]; P=.025) and one-year reinterventions (OR 1.4; [1.0-1.9]; P=.039). Unadjusted mid-term survival was lower for patients with neck characteristics outside of IFU than for patients without (5-year survival 84.0% vs. 86.7%, log-rank<.001). However, after adjustment, survival was similar for patients with neck characteristics outside of IFU to those within (HR: 1.1; [1.0-1.3]; P=.22).

CONCLUSION

Neck characteristics outside of IFU are independently associated with completion type Ia endoleaks, perioperative mortality, one-year sac expansion and one-year reinterventions among patients undergoing elective EVAR. These results indicate that continued effort is needed to improve the proximal seal in patients with neck characteristics outside of IFU undergoing EVAR. Also, in patients with severe hostile neck characteristics, alternative approaches such as open repair, use of a fenestrated or branched device, or endoanchors should be considered.

Impact of proximal neck anatomy on short-term and mid-term outcomes after treatment of abdominal aortic aneurysms with new-generation low-profile endografts. Results from the multicentric "ITAlian north-east registry of ENDOvascular aortic repair with the BOltOn Treo endograft (ITA-ENDOBOOT)"

INTRODUCTION

The aim of the study was to evaluate the short-term and mid-term technical and clinical outcomes of the Bolton Treo endograft in subjects with abdominal aortic aneurysm (AAA) requiring endovascular aortic repair (EVAR) and assess if presence of hostile proximal neck would represent a risk factor for increased failure rates.

METHODS

A retrospective review of all consecutive patients who had undergone elective or non-elective EVAR with the Bolton Treo endograft at five institutions located in the North-East of Italy (January 2016-December 2020) was performed. The main exposure variable for this study was presence of hostile (HAN) or friendly (FAN) aortic neck.

RESULTS

A total of 137 consecutive patients were treated with the Bolton Treo endograft at participating institutions; of these 63 (46%) presented HAN while 74 (54%) had FAN. At baseline, no significant differences were observed in the distribution of demographics and comorbidities between study groups. Two type Ia endoleaks (EL) were detected at completion angiography, all in patients with HAN but none in patients with FAN (3% vs 0%, p=.04), but no type III EL were identified in the whole cohort. The median duration of follow-up in the study cohort was 30 months (IQR 22-34 months) and was similar between study groups (p=.87). At three-years, survival estimates were 89% and 91% (p=.82) in patients with HAN and FAN, respectively. At three years, patients with HAN had significantly lower freedom from type IA endoleak as compared with patients with FAN (87% vs 94%, p=.02). No significant differences were found between study groups in the three-year estimates of freedom from reinterventions (80% vs 86%, p=.28). Using cox proportional hazards, presence of type II EL (HR 3.15, 95%CI 1.18-8.5, p=.02) and presence of type IA EL (HR 4.22, 95%CI 1.39-12.85, p=.01) were found as independent predictors for reinterventions in univariate analysis, although they were no longer significant in the multivariate model. Freedom from sac increase >5mm at three years were not significantly different between study groups (92% vs 91%, p=.95).

CONCLUSIONS

Within a contemporary multicentric real-world experience, EVAR with the Bolton Treo endograft shows a satisfactory safety profile in the immediate postoperative phase and acceptable outcomes during mid-term follow-up. Presence of HAN is correlated with development of type Ia EL (either early following stent-graft implantation or late after EVAR) which, in turn, may represent a significant factor leading to reinterventions.

The TREO abdominal aortic stent-graft system

Endovascular aneurysm repair has become a primary treatment modality for patients with abdominal aortic aneurysms due to its less invasive nature and improved peri-operative mortality rates compared with conventional open surgery. Long-term, endovascular aneurysm repair is hindered by the need for reintervention due to a variety of reasons. Device improvements are directed toward improving these long-term outcomes. The current manuscript highlights some of the details of the Terumo Aortic TREO abdominal aortic stent-graft, which was approved in 2020 for clinical use by the US FDA. A brief review of the available clinical outcomes from the US trial, as well as experience in the rest of the world, are provided demonstrating its excellent performance.

Safety and effectiveness of the TREO stent graft for the endovascular treatment of abdominal aortic aneurysms

OBJECTIVE

The short- and mid-term outcomes of endovascular aortic aneurysm repair have made it a standard treatment of abdominal aortic aneurysms. However, newer generation devices have yet to demonstrate improved long-term rates for complications, reinterventions, and survival. The TREO stent graft is a latest generation device and was evaluated for approval in the United States.

METHODS

In a multicenter, nonrandomized, investigational device exemption clinical trial, we assessed the safety and effectiveness of the TREO device, with core laboratory assessment of the imaging studies and an independent adjudication of safety. The primary effectiveness endpoint was successful aneurysm treatment at 1 year. The primary safety endpoint was the incidence of major adverse events (MAE) at 30 days.

RESULTS

A total of 150 patients (132 men; 88.0%) with infrarenal abdominal aortic (87.3%) or aortoiliac (12.7%) aneurysms were enrolled. The data were normally distributed. The mean age was 71.7 ± 7.4 years. The MAE incidence at 30 days was 0.7%. One subject experienced two MAE: myocardial infarction and procedural blood loss of 1000 mL. The proportion of successful aneurysm treatment at 1 year was 93.1%. Longer term follow-up continues, with no aneurysm-related mortality at the latest follow-up. At 3 years, the cumulative all-cause mortality and incidence of type I and type III endoleaks was 10.7% (n = 16), 2.7% (n = 4), and 0% (n = 0), respectively. In addition, aneurysm sac shrinkage >5 mm at 3 years had occurred in 54.3% of patients, and 9.3% had required a secondary intervention (n = 14).

CONCLUSIONS

The safety and effectiveness of endovascular repair of abdominal aneurysms with TREO were demonstrated, with 93.1% successful aneurysm treatment at 1 year and aneurysm sac shrinkage >5 mm at 3 years in 54.3% of patients. Long-term follow-up continues to determine whether these favorable outcomes will be sustained.