Aortic necks of ruptured abdominal aneurysms dilate more than asymptomatic aneurysms after endovascular repair

A systematic review and meta-analysis of proximal aortic neck dilatation after endovascular abdominal aortic aneurysm repair

OBJECTIVE

To provide an updated systematic literature review summarizing current evidence on aortic neck dilatation (AND) after endovascular aortic aneurysm repair (EVAR) in patients with infrarenal abdominal aortic aneurysm.

METHODS

An extensive electronic search in major electronic databases was conducted between January 2000 and December 2021. Eligible for inclusion were observational studies that followed up with patients (n ≥ 20) undergoing EVAR with self-expanding endografts, for 12 or more months, evaluated AND with computed tomography angiography and provided data on relevant outcomes. The primary end point was the incidence of AND after EVAR, and the secondary end points were the occurrence of type Ia endoleak, stent graft migration, secondary rupture, and reintervention.

RESULTS

We included 34 studies with a total sample of 12,038 patients (10,413 men; median age, 71 years). AND was defined clearly in 18 studies, but significant differences in AND definition were evidenced. The pooled incidence of AND based on quantitative analysis of 16 studies with a total of 9201 patients (7961 men; median age, 72 years) was calculated at 22.9% (95% confidence interval [CI], 14.4-34.4) over a follow-up period ranging from 12 months to 14 years. The risk of a type Ia endoleak was significantly higher in AND patients compared with those without AND (odds ratio, 2.95; 95% CI, 1.10-7.93; P = .030). Similarly, endograft migration was more common in the AND group compared with the non-AND group (odds ratio, 5.95; 95% CI, 1.80-19.69; P = .004). The combined incidence of secondary rupture and reintervention did not differ significantly between the two groups, even though the combined effect was in favor of the non-AND group.

CONCLUSIONS

Proximal AND after EVAR is common and occurs in a large proportion of patients with infrarenal abdominal aortic aneurysm. AND can influence the long-term durability of proximal endograft fixation and is significantly related to adverse outcomes, often leading to reinterventions.

The Relationship Between Obstructive Sleep Apnea and Ruptured Intracranial Aneurysms

STUDY OBJECTIVES

The role of obstructive sleep apnea (OSA) in the overall outcome of ruptured intracranial aneurysms (RIAs) is unknown. We have investigated the role of OSA in overall outcome of RIAs.

METHODS

Data from 159 consecutive patients were retrospectively reviewed. A chi-square test and regression analysis were performed to determine the significant difference. A value of P < .05 was considered significant.

RESULTS

The prevalence of OSA in RIAs was fivefold higher in the nonaneurysm patient group, P = .002. The number of patients with hypertension (P < .0001), body mass index ≥ 30 (P < .0001), hyperlipidemia (P = .018), chronic heart disease (P = .002) or prior ischemic stroke (P = .001) was significantly higher in the OSA group. Similarly, the number of wide-neck aneurysms (P < .0001) and aneurysm > 7 mm (P = .004), poor Hunt and Hess grade IV-V (P = .005), vasospasms, (P = .03), and patients with poor Modified Rankin Scale scores (3-6) was significantly higher in the OSA group (P < .0001). Interestingly, for the first time in univariate (P = .01) and multivariate (P = .003) regression analysis, OSA was identified as an individual predictor of unfavorable outcome of RIAs. In addition, hypertension (P = .04), smoking (P = .049), chronic heart disease (P = .01), and Hunt and Hess grade IV-V (P = .04) were revealed as predictors of poor outcome of RIAs.

CONCLUSIONS

This is a novel study to determine the association between OSA and ruptured cerebral aneurysm in terms of comorbidities, size of aneurysm, severity of symptoms, and outcomes after treatment. In addition, for the first time, OSA is identified as a positive predictor of unfavorable outcome of RIAs.

No Difference in Neck Enlargement for Patients Treated With Double Proximal Self-Expandable Suprarenal Fixation Endografting

INTRODUCTION

Neck enlargement is well described in patients treated with self-expandable endografts for abdominal aortic aneurysms. Double endografting (ie, overlapping of stent grafts) occurs in patients with proximal cuffs or bifurcated to monoiliacal configuration conversions. When the aortic neck of patients receives 2 suprarenal fixation endografts, it may behave differently in terms of radial force and interaction of additional suprarenal stents extending to the visceral aorta.

METHODS

We performed a retrospective study comparing 2 groups. Group 1 included 18 patients treated with 2 proximal self-expandable endografts. Group 2 included 17 patients treated with 1 self-expandable endograft who were consecutively treated during the period of treatment in group 1. Neck measurements were analyzed in both groups preoperatively and in the last computed tomography scan during follow-up. Suprarenal, interrenal, juxtarenal, and infrarenal (at 5 and 10 mm) diameters, as well as interrenal and infrarenal (5 mm) areas, were measured.

RESULTS

There was no significant difference in baseline characteristics, initial neck measurements, and aneurysmal sac evolution including endoleaks between the groups. Both groups showed neck enlargement. Group comparisons of all parameters in posttreatment neck measurements showed no statistical change. Univariate analysis showed oversizing to be significant in interrenal diameter and area and infrarenal at 10 mm diameter; however, 2-way analysis of variance analysis showed that the interaction between oversizing and the number of stent grafts was not significant.

CONCLUSION

Neck enlargement occurs in patients with self-expandable endografts with a tendency to reach the size of the endograft in the long term. Double endografting seems to interact in the same way as simple endografting in the aortic neck. Although the main limitation of our study lies in the small sample size, the presence of an additional "double" stent graft does not appear to result in any differences in aortic neck dilatation when compared to a single stent graft.

Treatment of Abdominal Aortic Pathology

Abdominal aortic pathology is a diverse topic, ranging through a broad span of possible pathologies. The treatment options are equally vast, particularly with the ever-expanding endovascular techniques. In this article, we discuss management strategies for abdominal aortic aneurysms and aortic occlusive disease, because they represent some of the most common pathologies encountered in clinical scenarios.

Coexistence of obstructive sleep apnea worsens the overall outcome of intracranial aneurysm: a pioneer study

OBJECTIVE Obstructive sleep apnea (OSA) is associated with the progression of abdominal and thoracic aortic aneurysms. However, the role of OSA in the overall outcome of intracranial aneurysms (IAs) has not yet been established. Authors of this report investigated the role of OSA in the overall outcome of IAs. METHODS Radiological and clinical data on patients (from 2010 through 2015) with confirmed IA were retrospectively reviewed. Significant differences between the OSA and non-OSA groups were determined using a chi-square test. Logistic regression analysis was performed to identify the predictors of an unfavorable IA outcome. RESULTS Among the 283 patients with confirmed IAs, 45 patients (16%) were positively screened for OSA, a proportion that was significantly higher than the prevalence of OSA in nonaneurysmal neurosurgical patients (4%, p = 0.008). The percentage of patients with hypertension (p = 0.018), a body mass index ≥ 30 kg/m² (p < 0.0001), hyperlipidemia (p = 0.034), diabetes mellitus (p = 0.005), chronic heart disease (CHD; p = 0.024), or prior stroke (p = 0.03) was significantly higher in the OSA group than in the non-OSA group. Similarly, the percentage of wide-necked aneurysms (p = 0.00001) and patients with a poor Hunt and Hess Grade IV-V (p = 0.01) was significantly higher in the OSA group than in the non-OSA group. In addition, the percentage of ruptured aneurysms (p = 0.03) and vasospasms (p = 0.03) was significantly higher in the OSA group. The percentage of patients with poor modified Rankin Scale (mRS) scores (3-6) was significantly higher in the OSA group (p = 0.03). A separate cohort of patients with ruptured IAs showed similar results. In both univariate (p = 0.01) and multivariate (p = 0.04) regression analyses, OSA was identified as an individual predictor of an unfavorable outcome. In addition, hypertension and prior stroke were revealed as predictors of a poor IA outcome. CONCLUSIONS Complications of IA such as rupture and vasospasm are often the consequence of uncontrolled OSA. Overall outcome (mRS) of IAs is also affected by the co-occurrence of OSA. Therefore, the coexistence of OSA with IA affects the outcome of IAs. Obstructive sleep apnea is a risk factor for a poor outcome in IA patients.

A Systematic Review of Proximal Neck Dilatation After Endovascular Repair for Abdominal Aortic Aneurysm

Purpose: To provide an updated systematic literature review and summarize current evidence on proximal aortic neck dilatation (AND) after endovascular aneurysm repair (EVAR). Methods: A review of the English-language medical literature from 1991 to 2015 was conducted using MEDLINE and EMBASE to identify studies reporting AND after EVAR. Studies considered for inclusion and full-text review fulfilled the following criteria: (1) reported AND after EVAR, (2) included at least 5 patients, and (3) provided data on AND quantification. The search identified 26 articles published between 1998 and 2015 that encompassed 9721 patients (median age 71.8 years; 9439 men). Results: AND occurred in 24.6% of patients (95% CI 18.6% to 31.8%) over a period ranging from 15 months to 9 years after EVAR. No significant dilatation of the suprarenal part of the aorta was reported by most studies. The incidence of combined clinical events (endoleak type I, migration, reintervention during follow-up) was higher in the AND group (26%) when compared with 2% in the group without AND (OR 28.7, 95% CI 5.43 to 151.67, p<0.001). Conclusion: AND affects a considerable proportion of EVAR patients and was related to worse clinical outcome, as indicated by increased rates of type I endoleak, migration, and reinterventions. Future studies should focus on a better understanding of the pathophysiology, predictors, and risk factors of AND, which could identify patients who may warrant a different EVAR strategy and/or a closer post-EVAR surveillance strategy.

Influence of Pulmonary Status and Diabetes Mellitus on Aortic Neck Dilatation following Endovascular Repair of Abdominal Aortic Aneurysms: A EUROSTAR Report

Purpose:

To elucidate the association of impaired pulmonary status (IPS) and diabetes mellitus (DM) with clinical outcome and the incidences of aortic neck dilatation and type I endoleak after elective endovascular infrarenal aortic aneurysm repair (EVAR).

Methods:

In 164 European institutions participating in the EUROSTAR registry, 6383 patients (5985 men; mean age 72.4±7.6 years) underwent EVAR. Patients were divided into patients without versus with IPS or with/without DM. Clinical assessment and contrast-enhanced computed tomography (CT) were performed at 1, 3, 6, 12, 18, and 24 months and annually thereafter. Cumulative endpoint analysis comprised death, aortic rupture, type I endoleak, endovascular reintervention, and surgical conversion.

Results:

Prevalence of IPS was 2733/6383 (43%) and prevalence of DM was 810/6383 (13%). Mean follow-up was 21.1±18.4 months. Thirty-day mortality, AAA rupture, and conversion rates did not differ between patients with versus without IPS and between patients with versus without DM. All-cause and AAA-related mortality, respectively, were significantly higher in patients with IPS compared to patients with normal pulmonary status (31.0% versus 19.0%, p<0.0001 and 6.8% versus 3.3%, p=0.0057) throughout follow-up. In multivariate analysis adjusted for smoking, age, gender, comorbidities, fitness for open repair, co-existing common iliac aneurysm, neck and aneurysm size, arterial angulations, aneurysm classification, endograft oversizing >15%, and type of stent-graft, the presence of IPS was not associated with significantly higher rates of aortic neck dilatation (30.6% versus 38.0%, p>0.05) and did not influence cumulative rates of type I endoleak, endovascular reintervention, or conversion to open surgery (p>0.05). Similarly, the presence of DM did not influence the above-mentioned study endpoints.

Conclusion:

In contrast to observations regarding the natural course of AAAs, impaired pulmonary status does not negatively influence aortic neck dilatation, while the presence of diabetes does not protect from these dismal events after EVAR.

Open Repair of Ruptured Abdominal Aortic Aneurysm: The Suitability of Endovascular Aneurysm Repair Does Not Influence Operative Mortality

Purpose:

We analyze the outcomes of open repair (OR) in patients with ruptured abdominal aortic aneurysm (RAAA) according to the anatomic suitability for endovascular aneurysm repair (EVAR).

Materials and Methods:

We reviewed retrospectively all consecutive RAAA patients who underwent OR from January 2005 to March 2014. All suspected patients underwent preoperative computed tomography (CT). Outcomes were major morbidities and mortality. Multivariate analysis was performed by using logistic regression adjusted by controlled variables; gender, Hardman index, maximal aneurysmal diameter, rupture type, perioperative transfusion requirement, and perioperative urinary output.

Results:

Among 54 consecutive patients with RAAA who underwent OR, 45 patients were included after exclusion of 9 patients (7, suprarenal; 1, infected; 1, inflammatory). Preoperative CT showed 27% (12/45) EVAR-suitable patients. Hostile neck anatomy was found in 88% (29/33) among unsuitable anatomy (UA) (n=33). The maximal aneurysmal diameter was statistically larger (83.1±21.0 mm vs. 68.8±12.3 mm, P=0.032) in the UA group. The 30-day mortality was 28.9% (13/45; 33% vs. 17% in UA group vs. suitable anatomy [SA] group, P=0.460; adjusted P=0.445). UA group had more patients with cardiac morbidity (55% vs. 25%, P=0.079; adjusted P=0.032; odds ratio, 12.914; 95% confidence interval, 1.238–134.675). There was no statistical difference in survival rate between SA and UA groups (74.1%, 74.1%, and 74.1% vs. 60.6%, 55.6%, and 32.4% at 1-, 3- and 5-year, respectively; P=0.145).

Conclusion:

In this study, relatively unfavorable outcomes were found in the EVAR-unsuitable group after OR in RAAA patients. However, unsuitable anatomy did not influence patient survival after OR by multivariate analysis.

Review of the Use of Ionizing Radiation in Endovascular Aneurysm Repair

Endovascular repair for aortic aneurysm (EVAR) is rapidly increasing in popularity. The nature of this intervention requires significant exposure to ionizing radiation both during the procedure and for postoperative surveillance, generally in the form of computed tomography. Here the authors review the literature for radiation exposure during EVAR, both for the patient and the physician.

Improved results in the management of ruptured abdominal aortic aneurysm may not be on the basis of endovascular aneurysm repair alone

Recent improvement in the survival of patients presenting with a ruptured abdominal aortic aneurysm (rAAA) has been credited to endovascular aneurysm repair (EVAR). We present our clinical series in the management of rAAA from 2007 to 2011. A total of 55 consecutive patient charts were reviewed. Thirty-eight patients underwent EVAR, 17 of the 55 patients did not have favorable anatomy for EVAR. Nine of the 17 patients underwent standard open repair. Eight patients underwent a 'hybrid repair' defined as suprarenal aortic endovascular balloon control followed by open repair. Overall 30-day mortality for all 55 patients was 22%. Mortality for the patients managed by endovascular aortic aneurysm repair was 26% compared with 22% with open repair. There were no deaths in the eight patients undergoing the hybrid repair. Endovascular balloon control of the aorta followed by open rAAA repair in patients who are not candidates for rEVAR has produced good results in our experience. Improved results being reported in the management of rAAA may not be on the basis of endovascular repair alone.

Emergency endovascular treatment of acute symptomatic or ruptured abdominal aortic aneurysm: a single-center experience

The purpose of this study is to report our early experience with endovascular treatment of patients with symptomatic non-ruptured (sAAA) or ruptured (rAAA) abdominal aortic aneurysms. Between September 2005 and September 2008, all patients with a diagnosis of sAAA or rAAA were evaluated for endovascular suitability. We did not consider hemodynamic instability to be a contraindication for endovascular aneurysm repair (EVAR). Patients whose aneurysm anatomy was not suitable for EVAR received open repair (OR). A total of 46 patients with sAAA or rAAA underwent emergency EVAR: in particular, 18/46 patients were treated for sAAA and 28/46 for rAAA. Successful stent-graft deployment was achieved in 44 patients (96%); we had two open surgical conversions. The 30-day mortality rate was 19.5%. Nine patients died during the first 30 postoperative days: four patients died within 24 hours because of severe hypovolemic shock, two died of respiratory failure, one died as a result of bowel ischemia and two because of myocardial infarction after hospital discharge. Complete follow-up data were available for 35 patients (median 185 days; range 30–730 days). In conclusion, endovascular treatment is feasible and the early experience is promising. The capability of offering EVAR and OR for sAAA and rAAA according to our experience suggests that EVAR and OR should be regarded as complementary techniques to improve outcome of patients with acute AAA.

The impact of radiation dose exposure during endovascular aneurysm repair on patient safety

OBJECTIVE

Endovascular aneurysm repair (EVAR) exposes patients to radiation during the procedure and in subsequent follow-up. The study goal was to calculate the radiation dose in our unit and compare it against other published data and national guidelines.

METHODS

All EVAR procedures were identified from a prospectively maintained database. Radiation dose, screening time, and volume of intravenous contrast during the procedure were reviewed. Radiation exposure from subsequent computed tomography (CT) imaging was included in the overall exposure. Results are expressed as mean +/- standard deviation.

RESULTS

From October 1998 to October 2008, 320 elective patients underwent EVAR. Mean screening time was 29.4 +/- 23.3 minutes, and the radiation dose was 11.7 +/- 7.1 mSv. The EVAR was an emergency in 64 patients. The mean screening time was 22.9 +/- 18.2 minutes, and the radiation dose was 13.4 +/- 8.6 mSv. During the first postoperative year, follow-up CT scans exposed the patients to 24.0 mSv, with 8.0 mSv in subsequent years. Abdominal radiographs added an additional 1.8 mSv each year.

CONCLUSION

EVAR and the follow-up investigations involve substantial amounts of radiation, with well-recognized carcinogenic risks. Because patient safety is paramount, radiation exposure should be minimized. This may be possible by standardizing radiation exposure throughout the United Kingdom by implementing national guidelines and considering other imaging modalities for follow-up.

No Difference in Medium-Term Outcome Between Zenith and Talent Stent-Grafts in Endovascular Aneurysm Repair

Background Many devices are available for endovascular aneurysm repair (EVAR). Our aim was to analyze morphological effects of the Zenith and Talent systems.

Methods Patients included underwent EVAR from June 1999 to June 2005 using a Zenith or Talent stent-graft, with computed tomography follow-up. Aortic dimensions over time and clinical outcome were analyzed.

Results Twenty-nine patients with Zenith stent-grafts and 33 with Talent devices were included. Mean preoperative age was similar (75.5 ± 6.0 years vs 74.2 ± 6.7 years; P = .29). Preoperative neck length was longer in the Zenith group (29.9 ± 15.2 mm vs 25.5 ± 10.8 mm; P = .10), and stent-graft oversizing was greater in the Talent patients (20.2% ± 7.9% vs 23.0% ± 11.3%). There was proximal aortic dilatation and aneurysm sac shrinkage in each group. Complication rates were comparable, with 83% of both groups free from 10-mm migration.

Conclusion Although device designs differ, there is no difference in clinical outcome between Zenith and Talent stent-grafts. Migration rates were not influenced by suprarenal fixation.

Endovascular Ruptured Abdominal Aortic Aneurysm Repair (EVRAR): A Systematic Review

BACKGROUND

To review evidence supporting the use of endovascular ruptured aneurysm repair (EVRAR) for treatment of ruptured abdominal aortic aneurysm (RAAA).

METHODS

A systematic review of the medical literature was performed for relevant studies. We searched a number of electronic databases and hand-searched relevant journals until November 2006 to identify studies for inclusion. We considered studies in which patients with a confirmed ruptured abdominal aortic aneurysm were treated with EVRAR, which reported endpoints of mortality and major complications.

RESULTS

There was 1 randomised controlled trial (RCT), 33 non-randomised case series (24 retrospective and 9 prospective) reports were identified comparing EVRAR (n=891) with conventional open surgical repair for the treatment of RAAA. Whilst no benefit in the primary outcome of mortality was noted in the only RCT, evidence from non-randomised studies suggest that EVRAR is feasible in selected patients, where it may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, early complications, and mortality.

CONCLUSIONS

For the treatment of symptomatic or ruptured abdominal aortic aneurysm, emergency endovascular repair (EVRAR) is feasible in selected patients, with early outcomes comparable to best conventional open surgical repair for the treatment of RAAA.

Prosthetic stent graft infection after endovascular abdominal aortic aneurysm repair

OBJECTIVE

The purpose of this report is to discuss the incidence, diagnosis, and management of stent graft infections after endovascular aneurysm repair (EVAR).

METHODS

Data were collected from the hospital database and medical case notes for all patients with infected endografts after elective or emergency EVAR for abdominal aortic aneurysm (AAA) during the last 8 years in two university teaching hospitals in Northern Ireland. The data included the patient's age, gender, presentation of sepsis, treatment offered, and the ultimate outcome. The diagnosis of graft-related sepsis was established by a combination of investigations including inflammatory markers, labelled white cell scan, computed tomography (CT) scan, microbiology cultures, and postmortem examination.

RESULTS

Graft-related septic complications occurred in six of 509 patients, including 433 elective repairs and 76 emergency endografts for ruptured AAA. Two patients presented with left psoas abscess and were treated successfully with extra-anatomic bypass and removal of the infected stent graft. Two more patients presented with infected graft without other evidence of intra-abdominal sepsis: one underwent successful removal of the infected prosthesis with extra-anatomical bypass, and the other was treated conservatively and died of progressively worsening sepsis. The fifth patient presented with unexplained fever and died suddenly, with a postmortem diagnosis of aortoenteric fistula and ruptured aneurysm. The last patient presented with an aortoenteric fistula, was treated conservatively in view of concurrent myelodysplasia, and died of possible aneurysm rupture.

CONCLUSION

This report emphasizes the need for continued awareness of potential graft-related septic complications in patients undergoing EVAR of AAA. Attention to detail with regard to sterility and antibiotic prophylaxis during stent grafting and during any secondary interventions is vital in reducing the risk of infection. In addition, early recognition and prompt treatment are essential for a successful outcome.