Clinical Practice Guidelines for Endovascular Abdominal Aortic Aneurysm Repair: Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association

Predictors of overall mortality after endovascular abdominal aortic repair - A single centre study

OBJECTIVES

A current and ongoing challenge is to reduce patient mortality after endovascular abdominal aortic repair (EVAR). This study aimed to assess the predictors of all-cause mortality after EVAR.

METHODS

Data regarding the demographic characteristics, comorbidities, laboratory values, selected anatomical factors, post-EVAR treatment, surveillance and complications of patients who underwent elective EVAR for non-ruptured abdominal aortic aneurysm (AAA) between January 2010 and January 2021 were evaluated. Mortality was assessed until 10 October 2023. Multivariate analyses were performed after adjusting for age, hypertension, diabetes mellitus, dyslipidaemia, sex, smoking, number of lumbar arteries, patency of inferior mesenteric artery (IMA), IMA diameter and reinterventions.

RESULTS

This study included 196 patients (183 men and 13 women) with a mean age of 72.4 ± 7.67 years. The overall mortality rate during a mean follow-up period of 5.75 ± 3.1 years was 50.0% (N = 98). The 2-, 5- and 10-year mortality rates were 9.7%, 32.0% and 66.6%, respectively. The mortality rates decreased by 59% in patients with reinterventions (hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.23-0.73; p = .002) and by 59% in patients treated with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) (HR: 0.41; 95% CI: 0.26-0.66; p < .001). Chronic anticoagulation was associated with 2.09-fold higher mortality (HR: 2.09; 95% CI: 1.19-3.67; p = .010), and coronary artery disease (CAD) was associated with 1.74-fold higher mortality (HR: 1.74; 95% CI: 1.09-2.78; p = .021). Pre-EVAR AAA diameter and 1-year post-EVAR sac diameter were positively associated with mortality (HR: 1.05; 95% CI: 1.03-1.08; p < .001, and HR: 1.05; 95% CI: 1.03-1.07; p < .001, respectively), that is, an increase of pre-EVAR and/or 1-year post-EVAR AAA diameter by 1 mm was associated with a 5% higher risk of all-cause mortality.

CONCLUSIONS

Reinterventions and treatment with ACE inhibitors or ARBs may be associated with decreased post-EVAR mortality. A greater pre-EVAR, a post-EVAR AAA diameter, CAD and chronic anticoagulation were associated with higher all-cause mortality post-EVAR.

Anesthetic Considerations in Combined TAVR and Aortic Endovascular Procedures, a Case Report

ABSTRACT

We report a case of simultaneous transcatheter aortic valve replacement and endovascular aneurysm repair. Our aim was to advocate the role of local and regional anesthesia as a key contributor in maintaining hemodynamic stability and avoiding abrupt blood pressure change. Endovascular combined procedures are gaining popularity for their numerous advantages. Nevertheless, they carry significant risks for their hemodynamic implications. It is imperative to acknowledge the modifications occurring after each correction and act accordingly. Different anesthesia approaches can dramatically influence hemodynamics; among all, we found local and regional anesthesia would better serve this objective.

One-stop transcatheter aortic valve replacement and fenestrated endovascular aortic aneurysm repair: A case report

The management of patients with severe aortic valve stenosis and an abdominal aortic aneurysm is a real therapeutic challenge. Minimally invasive treatment is more beneficial than open surgery for treating both aortic valve stenosis and abdominal aortic aneurysm. We present a case of a 77-year-old male initially treated with a 26 mm Sapien 3 transcatheter aortic valve replacement. Subsequently, using the same femoral access points, a custom fenestrated endoprosthesis and stents in digestive trunks and renal arteries were implanted. Follow-up imaging revealed no dysfunction of the valve, endoprosthesis, or stents. This is the first reported successful concomitant management of significant aortic valve stenosis and infrarenal abdominal aortic aneurysm through transcatheter aortic valve replacement and fenestrated endovascular aortic aneurysm repair.

Abdominal Penetrating Aortic Ulcer and Endovascular Treatments: A Systematic Review and Meta-Analysis

BACKGROUND

Abdominal penetrating aortic ulcer (aPAU) is defined as an ulceration of the aortic intima and media lamina, even with rupture of the internal elastic lamina. Recently, there have been an increasing number of publications on endovascular treatment for aPAU. This review aimed to assess the efficacy and safety of endovascular treatment and provide clinicians with the latest evidence-based medical data.

METHODS

3 academic databases (Embase, PubMed, and Scopus) were systematically searched for literature reporting on aPAU from 1986 (the earliest appearance of the concept of aPAU) to September 1, 2021, and related data were collected and evaluated. A fixed/random effects model was used to construct the forest plots. Funnel plots and linear regression tests were used to assess the publication bias.

RESULTS

6 articles including 121 patients were included in the analysis. The average age was 71.4 years, with 72.7% of males and 85.6% with hypertension. Saccular aneurysms (SA) were the most prevalent complication (35.5%). Endovascular treatment had a perioperative mortality rate of .24% (95% CI, .00-2.70). The technical success rate was 99.15% (95% CI, 96.49-100). The type-II endoleak rate was 5.69% (95% CI, .00-12.13). The 1-year survival rate was 95.69% (95% CI, 90.49-100). The revascularization rate was 7.20% (95% CI, .07-14.32). Endovascular treatments for aPAU would lead to a high rate of technical success, few complications, and satisfactory 1-year survival.

CONCLUSIONS

aPAU are a common disease that mainly affects elderly males with hypertension and hyperlipidemia. Endovascular treatment is required when an ulcer progresses rapidly or manifests symptoms. Endovascular treatment is associated with high technical success, low complication, and satisfactory 1-year survival. Further investigation into the long-term results of endovascular treatment is necessary.

Establishment of a clinical nurse specialist-led, virtual aneurysm surveillance clinic

BACKGROUND

The COVID-19 pandemic has necessitated significant changes to the manner in which healthcare is delivered. Chief among these has been the need to rapidly adopt virtual, or telephone clinics as a means of reducing unnecessary patient exposure to hospitals and clinical care settings. We were greatly aided in our adoption of virtual clinics by our experience in the establishment and maintenance of a Clinical Nurse Specialist-led, virtual clinic for both abdominal aortic (AAA) and extra-aortic aneurysm (EAA) surveillance within our department since 2016. Patients undergoing surveillance for abdominal aortic aneurysm (AAA) require frequent and lifelong clinical review. Previous studies have shown that post-operative surveillance in particular is critical in prolonging survival in AAA patients and in the early detection of late complications particularly following endovascular repair (EVAR). Poor compliance with EVAR surveillance has been shown to result in worse outcomes.

AIM

The aim of this study was to evaluate the success of a nurse-led virtual clinic programme in terms of the safe management of patients undergoing AAA surveillance in a nurse-led virtual clinic.

RESULTS

Over the course of the 4-year period from 2016 to 2019, 1352 patients were enrolled in the virtual aneurysm surveillance clinic. The majority of patients each year were male, ranging from 78.2% in 2016 to 85.2% in 2017. The majority of patients encountered the service owing to pre-operative surveillance of an AAA, with this group comprising at least 65% of the total cohort of patients each year.Over the course of the 4-year period of the virtual clinic there were 1466 patient encounters. Each ambulatory day care centre (ADCC) attendance normally costs the hospital €149. Therefore, a total saving of €218,434 resulted from this initiative alone. No patient presented as an emergency with a ruptured aneurysm during the time period studied.

CONCLUSION

Patients with AAA can be safely kept under surveillance in a nurse-led virtual clinic. Our experience with this model of care proved to be particularly advantageous during the period of the early COVID-19 pandemic.

Guidelines for Central Venous Port Placement and Management (Abridged Translation of the Japanese Version)

The central venous port has been widely used for patients who require long-term intravenous treatments, and the number of palcement has been increasing. The Japanese Society of Interventional Radiology developed a guideline for central venous port placement and management to provide evidence-based recommendations to support healthcare providers in the decision-making process regarding the central venous port. The guideline consisted of two parts: (i) a comprehensive review of topics including preoperative preparation, techniques for placement or removal, complications, and maintenance methods and (ii) recommendations for the six clinical questions regarding blood vessels for central venous port placement, port implantation site, prophylactic antibiotic therapy, imaging guidance for puncture, disinfectant prior to accessing the central venous port, and the optimal procedure at the end of drug administration via the central venous port, generated on the basis of the rating quality of evidence by systematic review.

Translumbar type II endoleak embolization with a new liquid iodinated polyvinyl alcohol polymer: Case series and review of current literature

Purpose

To describe our experience with the use of a novel iodized Polyvinyl Alcohol Polymer liquid agent (Easyx) in type II endoleak treatment with translumbar approach.

Methods

Our case series is a retrospective review of patients with type II endoleak (T2E) treated with Easyx from December 2017 to December 2020. Indication for treatment was a persistent T2E with an increasing aneurysm sac ≥5 mm on computed tomography angiography (CTA) over a 6-month interval. Technical success was defined as the embolization of the endoleak nidus with reduction or elimination of the T2E on sequent CTA evaluation. Clinical success was defined as an unchanged or decreased aneurysm sac on follow-up CTA. Secondary endpoints included the presence of artifacts in the postprocedural cross-sectional tomographic imaging and post and intraprocedural complications.

Results

Ten patients were included in our retrospective analysis. All T2E were successfully embolized. Clinical success was achieved in 9 out of 10 patients (90%). The mean follow-up was 14 3-20 months. No beam hardening artifact was observed in follow-up CT providing unaltered imaging.

Conclusion

Easyx is a novel liquid embolic agent with lava-like characteristics and unaltered visibility on subsequent CT examinations. In our initial experience, Easyx showed to have all the efficacy requisites to be an embolization agent for type II EL management. Its efficacy, however, should be evaluated in more extensive studies and eventually compared with other agents.

BMI-Based organ doses in endovascular aneurysm repair interventions utilising Monte Carlo simulation

In this study, the effect of body-mass-index (BMI) on organ doses (ODs) during infrarenal endovascular-aneurysm-repair (EVAR) procedures was evaluated. Patient- and intra-operative data from fifty-nine EVAR procedures were inserted into VirtualDose-IR software to calculate ODs. For overweight, obesity class-I and obesity class-II, ODs were up to 147%, 412% and 775% higher than those for normal weight-patients, respectively. A large variation was observed in ODs published in literature mainly due to the differences in the software and the technical parameters used for the calculations.

An Image Information-Based Objective Assessment Method of Technical Manipulation Skills for Intravascular Interventions

The clinical success of vascular interventional surgery relies heavily on a surgeon's catheter/guidewire manipulation skills and strategies. An objective and accurate assessment method plays a critical role in evaluating the surgeon's technical manipulation skill level. Most of the existing evaluation methods incorporate the use of information technology to find more objective assessment models based on various metrics. However, in these models, sensors are often attached to the surgeon's hands or to interventional devices for data collection, which constrains the surgeon's operational movements or exerts an influence on the motion trajectory of interventional devices. In this paper, an image information-based assessment method is proposed for the evaluation of the surgeon's manipulation skills without the requirement of attaching sensors to the surgeon or catheters/guidewires. Surgeons are allowed to use their natural bedside manipulation skills during the data collection process. Their manipulation features during different catheterization tasks are derived from the motion analysis of the catheter/guidewire in video sequences. Notably, data relating to the number of speed peaks, slope variations, and the number of collisions are included in the assessment. Furthermore, the contact forces, resulting from interactions between the catheter/guidewire and the vascular model, are sensed by a 6-DoF F/T sensor. A support vector machine (SVM) classification framework is developed to discriminate the surgeon's catheterization skill levels. The experimental results demonstrate that the proposed SVM-based assessment method can obtain an accuracy of 97.02% to distinguish between the expert and novice manipulations, which is higher than that of other existing research achievements. The proposed method has great potential to facilitate skill assessment and training of novice surgeons in vascular interventional surgery.

FACTORS INFLUENCING FLUOROSCOPY TIME IN ENDOVASCULAR TREATMENT OF ABDOMINAL ANEURYSMS: A RETROSPECTIVE STUDY

Patients who undergo endovascular aortic aneurysm repair (EVAR) may require prolonged radiation exposure affected by several factors. The objectives of this study were to document fluoroscopy time (FT) during EVAR and identify possible factors that influence it. A retrospective analysis of a 180 patients' database with abdominal infrarenal aortic aneurysms submitted to EVAR during a 7-y period was performed. The FT is evaluated regarding risk factors and comorbidities, graft type and patient-related, clinical and technical parameters. FT's median (interquartile range) was 1011 (698-1500) s. Excluder and C3 Excluder were associated with significantly lower FT values when compared with other grafts. Hypertension, dyslipidemia, age ≥ 70 y, maximum aneurysm diameter ≥ 6 cm and procedure duration ≥2 h resulted in higher FT values. A significantly lower FT was found for the operations performed in the 7th y of the study's period compared with the previous 6 y, mainly because of the use of Excluder or C3 Excluder grafts. However, these grafts did not show any significant difference in FT values during the 7 y. A significant correlation between FT with age and procedure duration was found. Nevertheless, procedure duration is a poor FT predictor in linear and logistic regressions, although is significantly correlated with FT. Dyslipidemia, procedure duration and graft type are independent predictors of FT larger than the median, whereas only the procedure duration is a predictor for FT larger than the 75th percentile value. The identified factors regarding radiation protection issues should be considered when contemplating abdominal aortic aneurysm repair, however, without compromising the procedure's efficacy. Further work is necessary to identify more potential anatomical, clinical and technical factors affecting procedures' complexity and FT and patient radiation dose during EVAR interventions.

Iliofemoral artery predilation prior to transfemoral transcatheter aortic valve implantation in patients with aortic valve stenosis and advanced peripheral artery disease

OBJECTIVES

To investigate the feasibility and safety of percutaneous transluminal angioplasty (PTA) of the iliofemoral arteries (IFA) before transfemoral transcatheter aortic valve implantation (Tf-TAVI) in patients with advanced peripheral artery disease (PAD).

BACKGROUND

Although Tf-TAVI represents the access of choice, alternative vascular access routes are preferred for patients displaying advanced PAD. PTA of the IFA represents a less invasive option, broadening the spectrum of patients eligible for Tf-TAVI.

METHODS

All patients requiring PTA of the IFA before Tf-TAVI, between 2012 and 2021, were included. Primary efficacy endpoint was the rate of successful transcatheter heart valve (THV) delivery and implantation. Primary safety endpoint was the rate of PTA and access-site-related vascular complications, procedural- and in-hospital complications.

RESULTS

Among 2726 Tf-TAVI procedures, 59 patients required IFA predilation. Successful THV delivery and implantation was achieved in 57 (96.6%) patients, respectively. Sheath placement was achieved in 59 (100%) patients with only one minor dissection and no major vascular complications following iliofemoral PTA. Regarding access site complications, two (3.4%) vessel perforations and one (1.7%) vessel rupture were observed, with eight (13.5%) patients requiring unplanned endovascular interventions. There was one intraprocedural death due to THV-induced vessel laceration, while in-hospital all-cause mortality was 8.5% in the present high-risk patient cohort.

CONCLUSIONS

Predilation of IFA is safe and effective in patients with advanced PAD. Careful preprocedural planning is paramount in improving procedural safety and efficacy. This strategy has the potential to broaden the spectrum of patients eligible for Tf-TAVI.

Exploring the Effect and Mechanism of Si-Miao-Yong-An Decoction on Abdominal Aortic Aneurysm Based on Mice Experiment and Bioinformatics Analysis

Background

Abdominal aortic aneurysm (AAA) is a fatal disease characterized by high morbidity and mortality in old population. Globally, effective drugs for AAA are still limited. Si-Miao-Yong-An decoction (SMYAD), a traditional Chinese medicine (TCM) formula with a high medical value, was reported to be successfully used in an old AAA patient. Thus, we reason that SMYAD may serve as a potential anti-AAA regime.

Objective

The exact effects and detailed mechanisms of SMYAD on AAA were explored by using the experimental study and bioinformatics analysis.

Methods

Firstly, C57BL/6N mice induced by Bap and Ang II were utilized to reproduce the AAA model, and the effects of SMYAD were systematically assessed according to histology, immunohistochemistry, and enzyme-linked immunosorbent assay (ELISA). Then, network pharmacology was applied to identify the biological processes, pathways, and hub targets of SMYAD against AAA; moreover, molecular docking was utilized to identify the binding ability and action targets.

Results

In an animal experiment, SMYAD was found to effectively alleviate the degree of pathological expansion of abdominal aorta and reduce the incidence of Bap/Ang II-induced AAA, along with reducing the damage to elastic lamella, attenuating infiltration of macrophage, and lowering the circulating IL-6 level corresponding to the animal study, and network pharmacology revealed the detailed mechanisms of SMYAD on AAA that were related to pathways of inflammatory response, defense response, apoptotic, cell migration and adhesion, and reactive oxygen species metabolic process. Then, seven targets, IL-6, TNF, HSP90AA1, RELA, PTGS2, ESR1, and MMP9, were identified as hub targets of SMYAD against AAA. Furthermore, molecular docking verification revealed that the active compounds of SMYAD had good binding ability and clear binding site with core targets related to AAA formation.

Conclusion

SMYAD can suppress AAA development through multicompound, multitarget, and multipathway, which provides a research direction for further study.

Abdominal aortic aneurysm clinical practice guidelines: a methodological assessment using the AGREE II instrument

OBJECTIVES

Abdominal aortic aneurysm (AAA) clinical practice guidelines (CPGs) provide evidence-based information on patient management; however, methodological differences exist in the development of CPGs. This study examines the methodological quality of AAA CPGs using a validated assessment tool.

METHODS

Medline, EMBASE and online CPG databases were searched from 1946 to 31 October 2021. Full-text, English language, evidence-based AAA CPGs were included. Consensus-based CPGs, summaries of CPGs or CPGs which were only available on purchase were excluded. Five reviewers assessed their quality using the Appraisal of Guidelines for Research and Evaluation II instrument. An overall guideline assessment scaled score of ≥80% was considered as the threshold to recommend CPG use in clinical practice.

RESULTS

Seven CPGs were identified. Scores showed good inter-reviewer reliability (intraclass correlation coefficient 0.943, 95% CI 0.915 to 0.964). On average, CPGs performed adequately with mean scaled scores of over 50% in all domains. However, between CPGs, significant methodological heterogeneity was observed in all domains. Four CPGs scored ≥80% (European Society of Cardiology, the Society of Vascular Surgery, the European Society of Vascular Surgery and the National Institute of Health and Care Excellence), supporting their use in clinical practice.

CONCLUSIONS

Four CPGs were considered of adequate methodological quality to recommend their use in clinical practice; nonetheless, these still showed areas for improvement, potentially through performing economic analysis and trial application of recommendations. A structured approach employing validated CPG creation tools should be used to improve rigour of AAA CPGs. Future work should also evaluate recommendation accuracy using validated appraisal tools.

CT angiography for the assessment of EVAR complications: a pictorial review

Endovascular aneurysm repair (EVAR) is a minimally invasive treatment proposed as an alternative to open repair in patients with abdominal aortic aneurysms. EVAR consists in a stent-graft placement within the aorta in order to exclude the aneurysm from arterial circulation and reduce the risk of rupture. Knowledge of the various types of devices is mandatory because some stents/grafts are more frequently associated with complications. CT angiography is the gold standard diagnostic technique for preprocedural planning and postprocedural surveillance. EVAR needs long-term follow-up due to the high rate of complications. Complications can be divided in endograft device-related and systemic complications. The purpose of this article is to review the CT imaging findings of EVAR complications and the key features for the diagnosis.

Percutaneous implantation of peripherally inserted totally implantable venous access systems in the forearm in adolescent patients

BACKGROUND

Children with different underlying malignant diseases require long-term central venous access. As for port systems in a pectoral position, peripherally implanted port systems in the forearm revealed high levels of technical and clinical success in adult cohorts.

OBJECTIVE

To investigate the technical and clinical outcomes of percutaneous central venous port implantation in the forearm in adolescents.

MATERIALS AND METHODS

Between April 2010 and August 2020, 32 children ages 9 to 17 years with underlying malignancy received 35 totally implantable venous access ports (TIVAPs) in the forearm. All venous port systems were peripherally inserted under ultrasound guidance. Correct catheter placement was controlled by fluoroscopy. As primary endpoints, the technical success, rate of complications and catheter maintenance were analyzed. Secondary endpoints were the side of implantation, vein of catheter access, laboratory results on the day of the procedure, procedural radiation exposure, amount of contrast agent and reasons for port device removal.

RESULTS

Percutaneous TIVAP placement under sonographic guidance was technically successful in 34 of 35 procedures (97.1%). Procedure-related complications did not occur. During the follow-up, 13,684 catheter days were analyzed, revealing 11 complications (0.8 per 1,000 catheter-duration days), Of these 11 complications, 7 were major and 10 occurred late. In seven cases, the port device had to be removed; removal-related complications did not occur.

CONCLUSION

Peripheral TIVAP placement in the forearms of children is a feasible, effective and safe technique with good midterm outcome. As results are comparable with standard access routes, this technique may be offered as an alternative when intermittent venous access is required.

KERMA-AREA PRODUCT, ENTRANCE SURFACE DOSE AND EFFECTIVE DOSE IN ABDOMINAL ENDOVASCULAR ANEURYSM REPAIR

This study aims to evaluate patient radiation dose during fluoroscopically guided endovascular aneurysm repair (EVAR) procedures. Fluoroscopy time (FT) and kerma-area product (KAP) were recorded from 87 patients that underwent EVAR procedures with a mobile C-arm fluoroscopy system. Effective dose (ED) and organs' doses were calculated utilising appropriate conversion coefficients based on the recorded KAP values. Entrance surface dose (ESD) was calculated based on KAP values and technical parameters. The mean FT was 22.7 min (range 6.4-76.8 min), resulting in a mean KAP of 36.6 Gy cm2 (range 2.0-167.8 Gy cm2), a mean ED of 6.2 mSv (range 0.3-28.5 mSv) and a mean ESD of 458 mGy (range 26-2098 mGy). The corresponding median values were 17.4 min, 25.6 Gy cm2, 4.4 mSv and 320 mGy. The threshold of 2 Gy for skin erythema was exceeded in two procedures for a focus-to-skin distance (FSD) of 40 cm and six procedures when an FSD of 30 cm was considered. The highest doses absorbed by the adrenals, kidneys, spleen and pancreas and ranged between 3.7 and 313.3 mGy (average 66.8 mGy), 3.3 and 285.1 mGy (average 60.8 mGy), 1.3 and 111.1 mGy (average 23.7 mGy), 1.1 and 92.1 mGy (average 19.6 mGy), respectively. A wide range of patient doses was reported in the literature. The radiation dose received by the patients was comparative or lower than most of the previously reported values. However, higher doses can be revealed due to the X-ray system's non-optimum use and extended FTs, mainly affected by complex clinical conditions, patients' body habitus and vascular surgeon experience. The large variation of patient doses highlights the potential to optimise the EVAR procedure by considering the balance between the radiation dose and the required image quality. Additional studies need to be conducted in increasing the vascular surgeons' awareness regarding patient dose and radiation protection issues during EVAR procedures.

Repair of a late endoleak following complete proximal endograft fixation strut separation

Introduced as an alternative endograft for those with unfavorable anatomy, bare metal suprarenal fixation barbs have been widely used for endovascular abdominal aortic repair. Type I endoleaks result in continued perfusion of the aneurysm sac and warrant prompt reintervention. We describe an unusual presentation and endovascular management of a late type IA endoleak secondary to complete separation of the suprarenal fixation struts in a Cook endograft after an uncomplicated, emergent infrarenal endovascular abdominal aortic repair 5 years earlier.

Type II Endoleak Nidus Volume on Arterial and Delayed Phases of Initial CT Angiography after Endovascular Abdominal Aortic Aneurysm Repair Predicts Persistent Endoleak and Aneurysm Sac Enlargement

Purpose

To evaluate type II endoleak nidus volume (ENV) in the arterial phase (ENV_AP) and delayed phase (ENV_DP) of the first postoperative CT angiography (CTA) as a predictor of persistent endoleak and aneurysm sac enlargement at follow-up CTA in patients with endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm.

Materials and Methods

Ninety-three patients (mean age ± standard deviation, 72 years ± 8; range, 56-88 years) with EVAR and type II endoleak were included in a single-institution retrospective study conducted between March 1, 2005, and December 31, 2018. ENV_AP, ENV_DP, change of volume (ENV_DP-AP), and percentage of ENV_AP and ENV_DP in aneurysm sac volume (ASV) (ENV_AP/ASV%, ENV_DP/ASV%, respectively) were measured on first postoperative CTA images. The mean follow-up was 31.6 months ± 26.6 (range, 6-163.8 months). Patients were divided into two groups (group A, spontaneous resolution of endoleak without intervention [n = 29] and group B, persistent endoleak at follow-up CTA [n = 64]) and compared by using the Mann-Whitney U, Wilcoxon signed rank, and Pearson χ² tests. Receiver operating characteristic (ROC) analysis was used to compare accuracies of parameters at first postoperative CTA.

Results

The accuracy of ENV_DP (area under the ROC curve [AUC], 0.78) was superior to the accuracy of ENV_DP/ASV% (AUC, 0.76), ENV_DP-AP (AUC, 0.74), ENV_AP (AUC, 0.71), and ENV_AP/ASV% (AUC, 0.69) in indicating persistent endoleak. In group B, 46 patients (72%) showed ASV enlargement and 44 patients (69%) underwent endoleak embolization. ENV_AP (1.7 cm³ ± 2.9 vs 3.4 cm³ ± 4.2; P = .001), ENV_DP (2.9 cm³ ± 3.8 vs 8.0 cm³ ± 9.6; P < .001), ENV_DP-AP (1.1 cm³ ± 1.8 vs 4.5 cm³ ± 7.8; P < .001), ENV_AP/ASV% (0.9% ± 1.5 vs 1.7% ± 2.2; P = .003), and ENV_DP/ASV% (1.6% ± 2.2 vs 3.7% ± 3.6; P < .001) were smaller in group A than in group B.

Conclusion

ENV_DP of the first postoperative CTA is an accurate predictor of persistent endoleak compared with ENV_AP, and persistent endoleak is associated with aneurysm sac enlargement, in which earlier intervention is recommended.© RSNA, 2021.

Adherence to the RIGHT statement in Society of Interventional Radiology guidelines

Context

The Reporting Items for Practice Guidelines in Health Care (RIGHT) Statement was developed by a multidisciplinary team of experts to improve reporting quality and transparency in clinical practice guideline development.

Objective

To assess the quality of reporting in clinical practice guidelines put forth by the Society of Interventional Radiology (SIR) and their adherence to the RIGHT statement checklist.

Methods

In March 2018, using the 22 criteria listed in the RIGHT statement, two researchers independently documented adherence to each item for all eligible guidelines listed by the SIR by reading through each guideline and using the RIGHT statement elaboration and explanation document as a guide to determine if each item was appropriately addressed as listed in the checklist. To qualify for inclusion in this study, each guideline must have met the strict definition for a clinical practice guideline as set forth by the National Institute of Health and the Institute of Medicine, meaning they were informed by a systematic review of evidence and intended to direct patient care and physician decisions. Guidelines were excluded if they were identified as consensus statements, position statements, reporting standards, and training standards or guidelines. After exclusion criteria were applied, the two researchers scored each of the remaining clinical practice guidelines (CPGs) using a prespecified abstraction Google form that reflected the RIGHT statement checklist (22 criteria; 35 items inclusive of subset questions). Each item on the abstraction form consisted of a “yes/no” option; each item on the RIGHT checklist was recorded as “yes” if it was included in the guideline and “no” if it was not. Each checklist item was weighed equally. Partial adherence to checklist items was recorded as “no.” Data were extracted into Microsoft Excel (Microsoft Corporation) for statistical analysis.

Results

The initial search results yielded 129 CPGs in the following areas: 13 of the guidelines were in the field of interventional oncology; 16 in neurovascular disorders; five in nonvascular interventions; four in pediatrics; 25 in peripheral, arterial, and aortic disease; one in cardiac; one in portal and mesenteric vascular disease; 37 in practice development and safety; three in spine and musculoskeletal disorders; 14 in venous disease; five in renal failure/hemodialysis; and five in women’s health. Of the 46 guidelines deemed eligible for evaluation by the RIGHT checklist, 12 of the checklist items showed less than 25% adherence and 13 showed more than 75% adherence. Of 35 individual RIGHT statement checklist items, adherence was found for a mean (SD) of 22.9 items (16.3). The median number of items with adherence was 21 (interquartile range, 7.5–38).

Conclusion

The quality of reporting in interventional radiology guidelines is lacking in several key areas, including whether patient preferences were considered, whether costs and resources were considered, the strength of the recommendations, and the certainty of the body of evidence. Poor adherence to the RIGHT statement checklist in these guidelines reveals many areas for improvement in guideline reporting.

An Infected Popliteal Aneurysm after Plain Old Balloon Angioplasty

The case was a 76-year-old man with chronic limb-threatening ischemia. Plain old balloon angioplasty (POBA) was performed on the popliteal artery. Subsequently, he suffered from cellulitis around the POBA site, followed by reocclusion. Staphylococcus aureus was detected in a blood culture. After re-revascularization with POBA, both purulent gonitis and an infected popliteal aneurysm were observed to occur. We performed aneurysmectomy and bypass grafting with the saphenous vein and then continued antibiotic therapy. Although treatment consisted of endovascular therapy (EVT) with nothing left behind, management was difficult because of secondary infectious complications. We conclude that prophylactic antibiotics before EVT should be considered in such cases.

Utility of Noncontrast Magnetic Resonance Angiography for Aneurysm Follow-Up and Detection of Endoleaks after Endovascular Aortic Repair

Objective

To assess the noncontrast two-dimensional single-shot balanced turbo-field-echo magnetic resonance angiography (b-TFE MRA) features of the abdominal aortic aneurysm (AAA) status following endovascular aneurysm repair (EVAR) and evaluate to detect endoleaks (ELs).

Materials and Methods

We examined four aortic stent-grafts in a phantom study to assess the degree of metallic artifacts. We enrolled 46 EVAR-treated patients with AAA and/or common iliac artery aneurysm who underwent both computed tomography angiography (CTA) and b-TFE MRA after EVAR. Vascular measurements on CTA and b-TFE MRA were compared, and signal intensity ratios (SIRs) of the aneurysmal sac were correlated with the size changes in the AAA after EVAR (AAA prognoses). Furthermore, we examined six feasible b-TFE MRA features for the assessment of ELs.

Results

There were robust intermodality (r = 0.92–0.99) correlations and interobserver (intraclass correlation coefficient = 0.97–0.99) agreement. No significant differences were noted between SIRs and aneurysm prognoses. Moreover, “mottled high-intensity” and “creeping high-intensity with the low-band rim” were recognized as significant imaging findings suspicious for the presence of ELs (p < 0.001), whereas “no signal black spot” and “layered high-intensity area” were determined as significant for the absence of ELs (p < 0.03). Based on the two positive features, sensitivity, specificity, and accuracy for the detection of ELs were 77.3%, 91.7%, and 84.8%, respectively. Furthermore, the k values (0.40–0.88) displayed moderate-to-almost perfect agreement.

Conclusion

Noncontrast MRA could be a promising imaging modality for ascertaining patient follow-up after EVAR.

Outpatient Percutaneous Endovascular Abdominal Aortic Aneurysm Repair: A Single-Center Experience

PURPOSE

To evaluate the safety of outpatient percutaneous endovascular abdominal aortic repair (PEVAR) versus inpatient PEVAR without or with adjunct procedures.

MATERIALS AND METHODS

Between January 2012 and June 2019, a cohort of 359 patients comprising 168 (46.8%) outpatients and 191 (53.2%) inpatients who had undergone PEVAR were enrolled. All the patients were asymptomatic but had indications for endovascular aortic repair, ie, fit for intravenous anesthesia and anatomically feasible with standard devices. Patient sex, age, comorbidities, smoking status, type of anesthesia, adjunct procedures, type of graft device, operative times, mortality, complications, and readmissions were analyzed.

RESULTS

Median follow-up period was 16.5 months (interquartile range, 9-31 months). Except for a higher percentage of tobacco use (42.6% vs 28.8%; P = .04), dyslipidemia (39.7% vs 19.2%; P < .01), and use of local anesthesia (99.4% vs 82.2%; P < .01) in the outpatients, there was no significant difference in the type of graft and adjunct procedures used. No outpatient mortality occurred. There was no difference in the number, severity, and onset of complications (all P > .05). Outpatient unexpected same-day admission, 30-day readmission, and emergency department visit rates were 4.8%, 2.4% (P = .13), and 10% (P < .01), respectively. Operative times for outpatient PEVAR without adjunct procedures were shorter (P < .01).

CONCLUSIONS

Outpatient PEVAR can be performed with a safety profile similar to that of inpatient PEVAR. The unexpected same-day admission, 30-day readmission, and emergency department visit rates were low. The outpatient PEVARs without adjunct procedures took less time.

Simultaneous Transcatheter Aortic Valve Implantation and Infrarenal Aortic Aneurysm Repair for Severe Aortic Stenosis and Abdominal Aortic Aneurysm: Report of 2 Cases and Literature Review

The prevalence of concomitant abdominal aortic aneurysm (AAA) and severe aortic stenosis (AS) has been increasing in the elderly population. Both conditions have adverse outcomes, if not adequately managed. No clear recommendations are available in the literature until today, in regards of the management sequence making thus the decision-making challenging. We report 2 cases of AAA and significant AS treated with endovascular aortic repair (EVAR) and transcatheter aortic valve implantation (TAVI) during the same procedure and a review of the literature on this topic. Based on our experience, the combined procedure with TAVI followed by EVAR seems to be feasible, safe, and effective while detailed preoperative planning and a carefully tailored management strategy by a multidisciplinary team are essential.

Learn EVAR sizing from scratch: The results of a one-day intensive course in EVAR sizing and stent graft selection for vascular trainees

Background and aim

Recognition of structured training in endovascular aortic repair (EVAR) for vascular trainees is increasing. Nevertheless, how trainees can achieve sufficient skills in EVAR sizing and graft selection is sparsely described. The aim of this study was to investigate the effect of systematic training in basic EVAR sizing and graft selection on vascular surgery trainees using a validated assessment tool.

Methods

Sixteen vascular surgery trainees were included in an intensive 6-h hands-on workshop in aortic sizing and stent graft selection for EVAR with a trainer-to-trainee ratio of 1:2. After 1-h lecture, participants did 5 h of supervised training on increasingly complex cases. Finally, the participants were tested using a validated assessment tool.

Results

All participants were able to size the test-case and select a stent graft combination in 24:35 (13:30–48:20) min (median and range). The participants’ overall test scores (lower is better) were in median 17.9 (11.9–28.4). This did not differ from the scores of experienced EVAR operators 14.7 (11.7–25.2) (<200 EVAR’s) ( p = .32) but was inferior to the score of EVAR experts 11.2 (9.8 –18.7) (≥200 EVAR’s) ( p = .01). The sub-score for anatomical measurements was 10.6 (3.9–18.8) and comparable with the experienced group 9.7 (8.1–12.8) ( p = .83) but inferior to the expert operators 6.5 (5.2–10.2) ( p = .04). The sub-score for stent graft selection was 7.5 (4.9–14.1) and comparable with experienced operators scoring 4.5 (3.6–12.3) ( p = .09) but inferior to the expert operators score of 5.0 (3.6–8.4) ( p = .01).

Conclusion

This study presents the results of a standardised one-day basic EVAR sizing and graft selection workshop. Vascular surgery trainees with no prior EVAR experience learned to size and select stent grafts for a simple infra-renal AAA on par with experienced EVAR operators.

Changes in the Normal Infrarenal Aortic Length and Tortuosity in Elderly People

Purpose

To investigate the changes in the infrarenal aortic length and tortuosity in elderly patients.

Materials and Methods

We retrospectively reviewed the medical records and computed tomography (CT) scans of 857 patients who underwent surgery for colorectal cancer between August 2009 and July 2012. Among these patients, 48 patients who were aged ≥60 years, underwent follow-up CT at least 5 years after surgery, did not have aortic disease, and did not receive radiation therapy were enrolled. The aortic tortuosity index (ATI) was defined by dividing the distance along the central lumen line from the lowest renal artery to the aortic bifurcation (L1) by the straight-line distance from the lowest renal artery to the aortic bifurcation (L2). Aortic diameters were measured at the lowest renal artery level (D1) and 20 mm below (D2). A paired t-test and Wilcoxon signed-rank test were used to compare lengths and diameters between the initial and final CT scan. Spearman’s correlation analysis was performed to determine the correlations between time and the changes in L1 and ATI.

Results

The average follow-up period was 68 months. The mean changes in L1 and L2 were 0.69 mm and –0.59 mm, respectively, while the mean changes in D1 and D2 were 0.77 mm and 0.58 mm, respectively. The mean increase in ATI was 0.015. All findings were statistically significant. On Spearman’s correlation analysis, ΔL1 and ΔATI showed no correlation with follow-up duration.

Conclusion

The infrarenal aortic length and tortuosity of elderly patients increases at a slow rate over time.

A Methodology to Quantify the Geometrical Complexity of the Abdominal Aortic Aneurysm

The abdominal aortic aneurysm (AAA) anatomy influences the technical success of the endovascular aneurysm repair (EVAR), yet very few data regarding the aortic tree angles exist in the literature. This poses great limitations in the numerical analyses of endografts, constraining their design improvement as well as the identification of their operational limitations. In this study, a matrix Φ of 10 angles was constructed for the description of the pathological region and was implemented on a large dataset of anatomies. More specifically, computed tomography angiographies from 258 patients were analysed and 10 aortic angles were calculated per case, able to adequately describe the overall AAA shape. 9 dimensional variables (i.e. diameters and lengths) were also recorded. The median and extreme values of these variables were computed providing a detailed quantification of the geometrical landscape of the AAA. Moreover, statistical analysis showed that the identified angles presented no strong correlation with each other while no lateral or anterior/posterior symmetry of the AAA was identified. These findings suggest that endograft designers are free to construct any extreme case-studies with the values provided in a mix-and-match manner. This strategy can have a powerful effect in EVAR stent graft designing, as well as EVAR planning.

Risk Factors of Infection and Role of Antibiotic Prophylaxis in Totally Implantable Venous Access Port Placement: Propensity Score Matching

BACKGROUND

To evaluate risk factors of infection and effectiveness of preprocedural single-dose intravenous prophylactic antibiotic (PABX) during totally implantable venous access port (TIVAP) placement in preventing procedure-related infections.

METHODS

This was a retrospective single-institution multicenter study evaluating short-term (30-day) infection outcomes after TIVAP placement. Correlation between infection rates and clinical factors, including hematologic versus non-hematologic malignancy, inpatient versus outpatient status, single versus double lumen and PABX, was investigated using univariate and multivariable analysis in the overall study population as well as the propensity-score-matched cohort.

RESULTS

Overall, 5967 patients underwent TIVAP placement from 2005 to 2016, of which 3978 (67%) patients received PABX. On propensity score matching, 1952 patients with PABX were matched to the same number of patients without PABX. TIVAP was removed due to infection concern in 48 patients in unmatched and 30 patients in matched population. There was no difference in the rate of infection between those who received PABX and those who did not in both unmatched and matched population (p = 0.5387 and 0.9999). Although infection rate was significantly higher in patients who had TIVAP placement in inpatient setting (p < 0.0001), who received a double-lumen TIVAP (p < 0.0001), or who had hematologic malignancy (p = 0.0004) on univariate analysis, inpatient status was the sole factor associated with higher rate of TIVAP infection on multivariable analysis of both overall (odds ratio 2.31, p < 0.0001) and matched populations (odds ratio 4.36, p = 0.0004).

CONCLUSION

Placement of TIVAP in inpatient setting increases the risk of TIVAP infection. PABX before TIVAP placement does not prevent short-term procedure-related infections.

Frontiers of Medical Robotics: From Concept to Systems to Clinical Translation

Medical robotics is poised to transform all aspects of medicine—from surgical intervention to targeted therapy, rehabilitation, and hospital automation. A key area is the development of robots for minimally invasive interventions. This review provides a detailed analysis of the evolution of interventional robots and discusses how the integration of imaging, sensing, and robotics can influence the patient care pathway toward precision intervention and patient-specific treatment. It outlines how closer coupling of perception, decision, and action can lead to enhanced dexterity, greater precision, and reduced invasiveness. It provides a critical analysis of some of the key interventional robot platforms developed over the years and their relative merit and intrinsic limitations. The review also presents a future outlook for robotic interventions and emerging trends in making them easier to use, lightweight, ergonomic, and intelligent, and thus smarter, safer, and more accessible for clinical use.

Infectious complications of endoarterial interventional radiology: protocol for an observational study of a longitudinal national cohort of patients assessed in the French hospital discharge database (MOEVA study)

Around seven million patients undergo endoarterial interventional radiology procedures (EAIRP) annually worldwide. These procedures have become part of the standard repertoire of vascular surgery. However, the healthcare-associated infections related to these procedures are relatively unknown. Prevalence and adverse outcome of infectious complication (IC) post-EAIRP may be underestimated. We aim to provide national trend estimation of EAIRP incidence and outcome in France. METHODS AND ANALYSIS: From the French Common Classification of Medical Acts, we will define four categories of EAIRP. We will collect procedures via the French nationwide hospital discharge database, called Programme de Médicalisation des Systèmes d'Information (PMSI) and derived from the Diagnosis Related Group system. Various combinations to identify the numerator will be employed according to a pre-established algorithm. Technical data wrangling tools facilitating the use of PMSI will be developed to obtain a clean and well-structured database ready for statistical analysis. This protocol will require competences in medicine, epidemiology, statistics, data processing and techniques through various stages of the study. The cohort will contain the denominator (the first act of the first stay of each patient) and the corresponding numerator (the IC which will occur during the first stay). ETHICS AND DISSEMINATION: No nominative, sensitive or personal data on patients have been collected. The study of the MOrtality and infectious complications of therapeutic EndoVAscular interventional radiology (MOEVA) study does not involve humans, and falls within the scope of the French Reference Methodology MR-004 according to 2016-41 law dated 26 January 2016 on the modernisation of the French health system. Our study involves the reuse of already recorded data, which require neither information or non-opposition of the included individuals. Access to linked ANOnymous (ANO) file in the PMSI databases was approved by the French National Commission for Data Protection and Liberties (CNIL number 1564135). The results will be disseminated through a peer-reviewed publication.

Contrast-enhanced ultrasound and/or colour duplex ultrasound for surveillance after endovascular abdominal aortic aneurysm repair: a systematic review and economic evaluation

BACKGROUND

Endovascular abdominal aortic aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) is less invasive than open surgery, but may be associated with important complications. Patients receiving EVAR require long-term surveillance to detect abnormalities and direct treatments. Computed tomography angiography (CTA) has been the most common imaging modality adopted for EVAR surveillance, but it is associated with repeated radiation exposure and the risk of contrast-related nephropathy. Colour duplex ultrasound (CDU) and, more recently, contrast-enhanced ultrasound (CEU) have been suggested as possible, safer, alternatives to CTA.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of imaging strategies, using either CDU or CEU alone or in conjunction with plain radiography, compared with CTA for EVAR surveillance.

DATA SOURCES

Major electronic databases were searched, including MEDLINE, EMBASE, Science Citation Index, Scopus' Articles-in-Press, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE) and NHS Economic Evaluation Database from 1996 onwards. We also searched for relevant ongoing studies and conference proceedings. The final searches were undertaken in September 2016.

METHODS

We conducted a systematic review of randomised controlled trials and cohort studies of patients with AAAs who were receiving surveillance using CTA, CDU and CEU with or without plain radiography. Three reviewers were involved in the study selection, data extraction and risk-of-bias assessment. We developed a Markov model based on five surveillance strategies: (1) annual CTA; (2) annual CDU; (3) annual CEU; (4) CDU together with CTA at 1 year, followed by CDU on an annual basis; and (5) CEU together with CTA at 1 year, followed by CEU on an annual basis. All of these strategies also considered plain radiography on an annual basis.

RESULTS

We identified two non-randomised comparative studies and 25 cohort studies of interventions, and nine systematic reviews of diagnostic accuracy. Overall, the proportion of patients who required reintervention ranged from 1.1% (mean follow-up of 24 months) to 23.8% (mean follow-up of 32 months). Reintervention was mainly required for patients with thrombosis and types I-III endoleaks. All-cause mortality ranged from 2.7% (mean follow-up of 24 months) to 42% (mean follow-up of 54.8 months). Aneurysm-related mortality occurred in < 1% of the participants. Strategies based on early and mid-term CTA and/or CDU and long-term CDU surveillance were broadly comparable with those based on a combination of CTA and CDU throughout the follow-up period in terms of clinical complications, reinterventions and mortality. The economic evaluation showed that a CDU-based strategy generated lower expected costs and higher quality-adjusted life-year (QALYs) than a CTA-based strategy and has a 63% probability of being cost-effective at a £30,000 willingness-to-pay-per-QALY threshold. A CEU-based strategy generated more QALYs, but at higher costs, and became cost-effective only for high-risk patient groups.

LIMITATIONS

Most studies were rated as being at a high or moderate risk of bias. No studies compared CDU with CEU. Substantial clinical heterogeneity precluded a formal synthesis of results. The economic model was hindered by a lack of suitable data.

CONCLUSIONS

Current surveillance practice is very heterogeneous. CDU may be a safe and cost-effective alternative to CTA, with CTA being reserved for abnormal/inconclusive CDU cases.

FUTURE WORK

Research is needed to validate the safety of modified, more-targeted surveillance protocols based on the use of CDU and CEU. The role of radiography for surveillance after EVAR requires clarification.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016036475.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Short-term and Midterm Results of Fenestrated Anaconda Endograft in Patients with Previous Endovascular Aneurysm Repair

PURPOSE

To review short-term and midterm results of the fenestrated Anaconda stent graft in management of patients with pre-existing endovascular aortic stent graft and persistent type 1a endoleak.

MATERIALS AND METHODS

This single-center retrospective study assessed all consecutive patients with type 1a endoleak and pre-existing endovascular aneurysm repair (EVAR) treated with fenestrated Anaconda stent grafts. Ten patients (9 males; mean age 78 y) with mean follow-up of 22.4 months ± 13 were included. Average aneurysm size was 80.1 mm (range, 62-101 mm). Mean time for conversion to fenestrated EVAR following original EVAR was 53.7 months (range, 22-101 months; median 54 months). Technical and clinical success; anatomic features, including aortic tortuosity, side vessel angulation, and stenosis; complications; and reinterventions were recorded.

RESULTS

The technical success rate was 90%. There was no open conversion and no 30-day mortality, leading to a clinical success rate of 100%. Five of 10 patients demonstrated an aortic tortuosity index of grade 2 or 3. Additional hostile anatomy that made side vessel catheterization challenging was observed in 15 vessels (45%) with a stenosis of ≥ 50% (related to atherosclerotic disease or struts of indwelling prosthesis) and 21 vessels (66%) with ≤ 70° angulation. Two reinterventions, renal artery stent angioplasty and renal artery covered stent extension, were observed at 2 and 13 months.

CONCLUSIONS

Use of the fenestrated Anaconda endograft in patients with type 1a endoleaks following previous EVAR is safe, feasible, and offers some technical features that facilitate overcoming certain anatomic difficulties.

Normal values of aortic dimensions assessed by multidetector computed tomography in the Copenhagen General Population Study

Aims

Accurate assessment of aortic dimensions can be achieved using contrast-enhanced computed tomography. The aim of this study was to define normal values and determinants of aortic dimensions throughout multiple key anatomical landmarks of the aorta in healthy individuals from the Copenhagen General Population Study.

Methods and results

The study group consisted of 902 healthy subjects selected from 3000 adults undergoing cardiovascular thoracic and abdominal computed tomography-angiography (CTA), where systematic measurements of aortic dimensions were performed retrospectively. Individuals included were without any of the following predefined cardiovascular risk factors: (i) self-reported angina pectoris; (ii) hypertension; (iii) hypercholesterolaemia; (iv) taking cardiovascular prescribed medication including diuretics, statins, or aspirin; (v) overweight (defined as body mass index ≥30 kg/m2); (vi) diabetes mellitus (self-reported or blood glucose >8 mmol/L); and (vii) chronic obstructive pulmonary disease. Maximal aortic diameters were measured at seven aortic regions: sinuses of Valsalva, sinotubular junction, ascending aorta, mid-descending aorta, abdominal aorta at the diaphragm, abdominal aorta at the coeliac trunk, and infrarenal abdominal aorta. Median age was 52 years, and 396 (40%) were men. Men had significantly larger aortic diameters at all levels compared with women (P < 0.001). Multivariable analysis revealed that sex, age, and body surface area were associated with increasing aortic dimensions.

Conclusion

Normal values of maximal aortic dimensions at key aortic anatomical locations by contrast-enhanced CTA have been defined. Age, sex, and body surface area were significantly associated with these measures at all levels of aorta. Aortic dimensions follow an almost identical pattern throughout the vessel regardless of sex.

Comparing polymer-filled versus self-expanding endografts in Chinese patients

INTRODUCTION

We performed a single-center nonrandomized study on patients who underwent endovascular aneurysm repair using polymer-filled or other self-expanding endografts.

METHODS

Consecutive patients with asymptomatic infrarenal abdominal aortic aneurysms who underwent endovascular repair were retrospectively reviewed. They were divided into a polymer-filled ( n = 20) or self-expanding group ( n = 42). Baseline characteristics, operative mortality and morbidity, and follow-up data were compared.

RESULTS

Aneurysm diameter, neck and iliac morphologies did not differ between the two groups. Technical success was 100%. The 30-day mortality was 0% and 2.4% in the polymer-filled and self-expanding group, respectively. At a mean follow-up of 17 months, the changes in sac size were -2.1 mm and -5.1 mm ( p = 0.144) at one year, and -3.5 mm and -7.7 mm ( p = 0.287) at 2 years in the polymer-filled and self-expanding group, respectively. The polymer-filled group had 7 (35%) type II endoleaks, and the self-expanding group had 1 (2.4%) type Ia and 13 (31%) type II endoleaks. Neck diameter remained stable in the polymer-filled stent-grafts whereas there was progressive neck degeneration in the self-expanding group. The rates of reintervention and overall survival were similar in both groups. The presence of an endoleak was the only predictor of non-regression of the aneurysm (odds ratio = 17.00, 95% confidence interval: 4.46-64.88, p < 0.001).

CONCLUSION

Polymer-filled endografts had similar safety, effectiveness, and durability to other self-expanding endografts. The major advantage is the small iliofemoral access. They also have the potential long-term benefit of a more stable neck.

Incidental extravascular findings in CT angiograms in patients post endovascular abdominal aortic aneurysm repair: clinical relevance and frequency

Background

To evaluate the incidence and clinical relevance of extravascular incidental findings (EVIF), particularly malignancies, in planning and follow-up CT angiograms (CTA) of the abdominal aorta in patients who underwent endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm. Retrospective study of 2203 planning and follow-up CTAs of 418 patients who underwent EVAR in a single tertiary centre between 2006 and 2015. CTA reports were scrutinized for EVIFs, which were classified according to clinical relevance, into (I) immediate, (II) potential and (III) no clinical relevance. Clinical follow-up and management were reviewed for significant findings. Follow-up CTAs of patients with incidental malignancies were re-reviewed by two consultant radiologists to evaluate if early missed malignant findings on previous CTAs were present.

Results

In total, 950 EVIFs were noted in 418 patients [31 females (7.4%), 387 males (92.6%); age range 63–93, mean age 79.0 years]. The number of patients with findings in each category were; Category I (115), Category II (165), Category III (304). Incidental malignant findings were reported in 51 patients (12.2%), of which 27 were noted on the initial CTA (6.5%) and 24 on follow-up CTAs (5.7%). Of the 24 patients with malignancies on follow-up CTAs, 13 had early malignant findings missed or misinterpreted on previous CTAs, while 11 had no significant abnormality even on retrospective review.

Conclusion

A high number of significant EVIFs, particularly incidental malignancies, can be identified in follow-up CTAs of patients who undergo EVAR. Specific ‘review areas’ when reporting surveillance CTAs can be recommended based on the findings of our study.

Repair of abdominal aortic aneurysms: preoperative imaging and evaluation

Imaging is a critical component of the pre-procedure evaluation and planning of endovascular aneurysm repair (EVAR). Imaging is the mainstay for proper assessment of procedural candidacy, relevant vascular anatomy, device selection, and surgical approach. Computed tomography angiography (CTA) has long been considered the preferred modality for pre-operative imaging and evaluation prior to EVAR. Recently, advances in image quality and software technology have further enhanced the proceduralist's ability to plan and perform EVAR. In this review, we highlight the current state of the art to provide interventionalists a contemporary assessment of the available tools for pre-operative imaging and evaluation prior to EVAR.

Abdominal aortic aneurysms: pre- and post-procedural imaging

Abdominal aortic aneurysm (AAA) is a relatively common, potentially life-threatening disorder. Rupture of AAA is potentially catastrophic with high mortality. Intervention for AAA is indicated when the aneurysm reaches 5.0-5.5 cm or more, when symptomatic, or when increasing in size > 10 mm/year. AAA can be accurately assessed by cross-sectional imaging including computed tomography angiography and magnetic resonance angiography. Current options for intervention in AAA patients include open surgery and endovascular aneurysm repair (EVAR), with EVAR becoming more prevalent over time. Cross-sectional imaging plays a crucial role in AAA surveillance, pre-procedural assessment, and post-EVAR management. This paper will discuss the current role of imaging in the assessment of AAA patients prior to intervention, in evaluation of procedural complications, and in long-term follow-up of EVAR patients.

Prevention of Kinked Stent Graft Limb Due to Severe Angulated Proximal Neck during Endovascular Repair for Abdominal Aortic Aneurysm

Although the technology of endovascular aortic repair (EVAR) for abdominal aortic aneurysm (AAA) is evolving that make it appealing for challenging anatomy, proximal aortic neck morphology, especially severe angulation, is still one of the most determinants for a successful procedure. We describe a patient of AAA with severely angulated proximal neck, in whom kinked stent graft limb occurred against severe angulation of proximal neck. Then, we suggested how to prevent this complication in the second patient. Our case demonstrated the stent graft limb could be kinked by severe aortic neck angulation, making it challenging. However, the kinked stent graft limb could be prevented by deploying stent graft limbs below the most severely angulated aortic neck intentionally.

Percutaneous access planning, techniques and considerations for endovascular aortic repair (EVAR)

Percutaneous endovascular aortic repair (EVAR) has transformed the field of aortic repair. As techniques and devices improve, interventionalists continue to expand the boundaries of what is possible, enabling these life-saving procedures to be performed on a wider range of more technically challenging cases. This article discusses endovascular access considerations for EVAR including; ultrasound guidance, preclose technique, access vessel options, innovative devices, and bailout strategies that interventionalists should be familiar with to optimize patient outcomes.

Complications of endovascular aneurysm repair of the thoracic and abdominal aorta: evaluation and management

In recent decades, endovascular aneurysm repair or endovascular aortic repair (EVAR) has become an acceptable alternative to open surgery for the treatment of thoracic and abdominal aortic aneurysms and other aortic pathologies such as the acute aortic syndromes (e.g., penetrating aortic ulcer, intramural hematoma, dissection). Available data suggest that endovascular repair is associated with lower perioperative 30-day all-cause mortality as well as a significant reduction in perioperative morbidity when compared to open surgery. Additionally, EVAR leads to decreased blood loss, eliminates the need for cross-clamping the aorta and has shorter recovery periods than traditional surgery. It is currently the preferred mode of treatment of thoracic and abdominal aortic aneurysms in a subset of patients who meet certain anatomic criteria conducive to endovascular repair. The main disadvantage of EVAR procedures is the high rate of post-procedural complications that often require secondary re-intervention. As a result, most authorities recommend lifelong imaging surveillance following repair. Available surveillance modalities include conventional radiography, computed tomography, magnetic resonance angiography, ultrasonography, nuclear imaging and conventional angiography, with computed tomography currently considered to be the gold standard for surveillance by most experts. Following endovascular abdominal aortic aneurysm (AAA) repair, the rate of complications is estimated to range between 16% and 30%. The complication rate is higher following thoracic EVAR (TEVAR) and is estimated to be as high as 38%. Common complications include both those related to the endograft device and systemic complications. Device-related complications include endoleaks, endograft migration or collapse, kinking and/or stenosis of an endograft limb and graft infection. Post-procedural systemic complications include end-organ ischemia, cerebrovascular and cardiovascular events and post-implantation syndrome. Secondary re-interventions are required in approximately 19% to 24% of cases following endovascular abdominal and thoracic aortic aneurysm repair respectively. Typically, most secondary reinterventions involve the use of percutaneous techniques such as placement of cuff extension devices, additional endograft components or stents, enhancement of endograft fixation, treatment of certain endoleaks using various embolization techniques and embolic agents and thrombolysis of occluded endograft components. Less commonly, surgical conversion and/or open surgical modification are required. In this article, we provide an overview of the most common complications that may occur following endovascular repair of thoracic and AAAs. We also summarize the current surveillance recommendations for detecting and evaluating these complications and discuss various current secondary re-intervention approaches that may typically be employed for treatment.

Editor's Choice - The Implications of Non-compliance to Endovascular Aneurysm Repair Surveillance: A Systematic Review and Meta-analysis

OBJECTIVE/BACKGROUND

Increasingly, reports show that compliance rates with endovascular aneurysm repair (EVAR) surveillance are often suboptimal. The aim of this study was to determine the safety implications of non-compliance with surveillance.

METHODS

The study was carried out according to the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An electronic search was undertaken by two independent authors using Embase, MEDLINE, Cochrane, and Web of Science databases from 1990 to July 2017. Only studies that analysed infrarenal EVAR and had a definition of non-compliance described as weeks or months without imaging surveillance were analysed. Meta-analysis was carried out using the random-effects model and restricted maximum likelihood estimation.

RESULTS

Thirteen articles (40,730 patients) were eligible for systematic review; of these, seven studies (14,311 patients) were appropriate for comparative meta-analyses of mortality rates. Three studies (8316 patients) were eligible for the comparative meta-analyses of re-intervention rates after EVAR and four studies (12,995 patients) eligible for meta-analysis for abdominal aortic aneurysm related mortality (ARM). The estimated average non-compliance rate was 42.0% (95% confidence interval [CI] 28-56%). Although there is some evidence that non-compliant patients have better survival rates, there was no statistically significant difference in all cause mortality rates (year 1: odds ratio [OR] 5.77, 95% CI 0.74-45.14; year 3: OR 2.28, 95% CI 0.92-5.66; year 5: OR 1.81, 95% CI 0.88-3.74) and ARM (OR 1.47, 95% CI 0.99-2.19) between compliant and non-compliant patients in the first 5 years after EVAR. The re-intervention rate was statistically significantly higher in compliant patients from 3 to 5 years after EVAR (year 1: OR 6.36, 95% CI 0.23-172.73; year 3: OR 3.94, 85% CI 1.46-10.69; year 5: OR 5.34, 95% CI 1.87-15.29).

CONCLUSION

This systematic review and meta-analysis suggests that patients compliant with EVAR surveillance programmes may have an increased re-intervention rate but do not appear to have better survival rates than non-compliant patients.

The endovascular management of neurofibromatosis-associated aneurysms: A systematic review

BACKGROUND

Neurofibroblastoma (NF) or Von Recklinghausen disease, is an autosomal dominant disorder affecting one in 3000 individuals. Cardinal features of NF include multiple café-au-lait macules, benign neurofibromas, and iris hamartomas. Albeit less common, vascular lesions of medium and large-sized arteries and veins are a well-recognized complication, which can lead to fatal consequences such as rupture.

METHOD

A systematic review was conducted as per the Preferred Reporting Instructions for Systematic Reviews and Meta-analysis (PRISMA) guidelines utilizing PubMed, EMBASE, and Cochrane databases.

RESULTS

There were 59 articles identified involving 66 patients (mean age 44.3 ± 30 years), of which 89% had neurofibromatosis type 1. There were 63.6% of patients who presented with aneurysm rupture, 33.3% presented with intact symptomatic aneurysms, and 3.1% presented with intact asymptomatic aneurysms. Anatomically, 4.5% of patients suffered from intracranial aneurysms; 12.1% suffered from visceral artery aneurysms (including hepatic, superior mesenteric, gastroduodenal and renal arteries), and other patients suffered from aneurysms within the chest, abdomen, pelvis, upper limbs and neck. Amongst the various endovascular procedures, coiling was performed in 83.3% of cases. There were 12 covered stents employed in 10 patients (18.2%), of which 7 were balloon-expandable grafts; 2 were self-expandable graft; 3 were not mentioned. The rates of major and minor complications were 15% and 6% respectively, with 4 cases (6%) of perioperative death. On a mean follow-up of 15 months (range 1.5-72 months), two patients developed a distant vascular lesion from the treated lesion.

CONCLUSION

Endovascular management is safe and effective even in hemodynamically unstable neurofibroblastoma patients at all ages. Vascular tree screening should be conducted in clinically suspicious patients to prevent fatal aneurysmal complications. A formal meta-analysis could not be performed due to the lack of randomized controlled trials.