Endovascular repair of popliteal aneurysms

Axillary artery aneurysm in a construction worker, presentation of a rare case

INTRODUCTION AND IMPORTANCE

Axillary artery aneurysm is a rare anomaly in the vascular system of the upper extremity. Most of these aneurysms are false aneurysms and secondary to trauma. They can cause compressive symptoms as well as thromboembolic events leading to limb loss or even rupture as a life-threatening complication.

CASE PRESENTATION

A 33-year-old man came to the vascular clinic with the complaint of a pulsating mass in his axilla from 2 months ago. He had mild pain in his arm and the mass was palpable in his axillary fossa. It was pulsating and non-tender on touch. CT angiography revealed the aneurysm and the patient was treated surgically using reversed greater saphenous vein for replacing the aneurysmal segment of the artery.

CLINICAL DISCUSSION

Axillary artery aneurysms may be true or false. Duplex scan and CT angiography can reliably differentiate them from each other. When the diagnosis is confirmed, open and endovascular approaches can be used to treat these vascular anomalies.

CONCLUSION

When a patient has an axillary mass, axillary artery aneurysm is one of the differential diagnoses and any clinician should keep this entity in his mind when approaching axillary masses.

The evolving role of endovascular therapy in the management of arterial thoracic outlet syndrome

OBJECTIVE

Over the past two decades, vascular surgeons have successfully incorporated endovascular techniques to the routine care of patients with arterial thoracic outlet syndrome (ATOS). However, no reports have documented the impact of endovascular therapy. This study describes the trends in management of ATOS by vascular surgeons and outcomes after both endovascular and open repair of the subclavian artery.

METHODS

We queried a single-institution, prospectively maintained thoracic outlet syndrome database for ATOS cases managed by vascular surgeons. For comparison, cases were divided into two equal time periods, January 1986 to August 2003 (P-1) vs September 2003 to March 2021 (P-2), and by treatment modality, open vs endovascular. Clinical presentation, outcomes, and the involvement of vascular surgeons in endovascular therapy were compared between groups.

RESULTS

Of 2200 thoracic outlet syndrome cases, 51 were ATOS (27 P-1, 24 P-2) and underwent 50 transaxillary decompressive operations. Forty-eight cases (92%) presented with ischemic symptoms. Thrombolysis was done in 15 (29%). During P-1, vascular surgeons performed none of the catheter-based interventions. During P-2, vascular surgeons performed 60% of the angiograms, 50% of thrombolysis, and 100% of stent grafting. Subclavian artery pathology included 16 aneurysms (31%), 15 stenoses (29%), and 19 occlusions (37%). Compared with open aneurysmal repair, endovascular stent graft repairs took less time (241 vs 330 minutes; P = .09), incurred lower estimated blood loss (103 vs 150 mL; P = .36), and had a shorter length of stay (2.4 vs 5.0 days; P = .10). Yet the endovascular group had decreased primary (63% vs 77%; P = .481), primary assisted (75% vs 85%; P = .590), and secondary patency rates (88% vs 92%; P = .719), at a mean follow-up time of 3.0 years for the endovascular group and 6.9 years for the open group (P = .324). These differences did not achieve statistical significance. Functionally, 84% of patients were able to resume work or school. A majority of patients (88%) had a good to excellent functional outcome based on their Derkash score. Somatic pain scores and QuickDASH (disabilities of the arm, shoulder, and hand) scores decreased postoperatively, 2.9 vs 0.8 (P = .015) and 42.6 vs 12.6 (P = .004), respectively.

CONCLUSIONS

This study describes the evolving role of endovascular management of ATOS over the past two decades and documents the expanded role of vascular surgeons in the endovascular management of ATOS at a single institution. Compared with open repair, stent graft repair of the subclavian artery may be associated with shorter operative times, less blood loss, but decreased patency, without changes in long-term functional outcomes.

Endovascular treatment of a popliteal artery aneurysm via transpedal approach: A case report

Popliteal artery aneurysm (PAA) has been increasingly treated with endovascular intervention in recent years. However, whether transpedal access can be utilized to treat PAA has not been widely reported. We report a case of successful treatment of a PAA with a covered stent via retrograde transpedal approach in an 80-year male with prohibitive surgical risk who initially failed antegrade approach. This case demonstrates the feasibility of treating PAA via a retrograde transpedal access in selected patients.

A Comparison of Endovascular Versus Open Repair of Popliteal Artery Aneurysms: An Updated Meta-Analysis

OBJECTIVE

Traditionally, popliteal artery aneurysms (PPAs) were treated via open repair (OR). However, more recently endovascular repair (EVR) approaches have become more common for the treatment of PPAs. The present meta-analysis therefore sought to conduct an up-to-date review of studies comparing the relative safety and efficacy of these 2 repair strategies. To that end, patient outcomes including primary patency, operating time, hospital stay duration, and re-intervention, amputation, and graft occlusion within 30 days were compared for these OR and EVR approaches.

METHODS

Studies in which OR and EVR were compared as treatments for PPAs were identified through systematic searching of the PubMed and Embase databases. Any studies either analyzing only one of these treatments in isolation or analyzing <5 patients were not included in this analysis. For all relevant studies, patient demographic information and outcome details were compiled. Risk of bias was analyzed using a modified Newcastle-Ottawa Scale. The odds ratios, mean differences, and hazard ratios (HRs) for patient outcomes were estimated using a random-effects model.

RESULTS

In total, we identified 17 relevant studies including a single randomized controlled trial and 16 retrospective cohort studies, incorporating 6887 total cases (1662 EVR and 5225 OR). The quality of evidence for all measured outcomes was deemed to be very low or low according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Rates of primary patency were found to be significantly higher for patients treated via OR relative to those treated via EVR (HR = 1.60; 95% confidence interval [CI]: 1.12-2.30; P = .03). Operative and hospitalization durations, in contrast, were significantly lower for patients treated via EVR. Patients treated via EVR also experienced significantly higher rates of graft thrombosis and reintervention within 30 days relative to patients treated via OR. However, no significant differences were observed between treatments with respect to rates of patient amputation (OR = 1.01; 95% CI: 0.55-1.85; P = .98).

CONCLUSIONS

The available data suggest that PPA repair via EVR is a safe alternative to OR, but that short-term graft thrombosis and reintervention rates are significantly greater for the former approach. Moreover, few studies to date have compared these techniques and those that were largely retrospective in nature with relatively low-quality evidence, making it difficult to make definitive statements regarding the relative safety and efficacy of these 2 repair strategies. Additional population-based large-scale studies are therefore essential in order to conduct a robust evaluation of the safety and utility of EVR as an alternative to OR for PPA repair.

Endovascular versus open repair of asymptomatic popliteal artery aneurysm

BACKGROUND

Popliteal artery aneurysm (PAA) is a focal dilatation and weakening of the popliteal artery. If left untreated, the aneurysm may thrombose, rupture or the clot within the aneurysm may embolise causing severe morbidity. PAA may be treated surgically by performing a bypass from the arterial segment proximal to the aneurysm to the arterial segment below the aneurysm, which excludes the aneurysm from the circulation. It may also be treated by a stent graft that is inserted percutaneously or through a small cut in the groin. The success of the procedure is gauged by the ability of the graft to stay patent over an extended duration. While surgical treatment is usually preferred in an emergency, the evidence on first line treatment in a non-emergency setting is unclear. This is an update of a review first published in 2014.

OBJECTIVES

To assess the effectiveness of an endovascular stent graft versus conventional open surgery for the treatment of asymptomatic popliteal artery aneurysms (PAA) on primary and assisted patency rates, hospital stay, length of the procedure and local complications.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 29 January 2019.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing endovascular stent grafting versus conventional open surgical repair in patients undergoing unilateral or bilateral prophylactic repair of asymptomatic PAAs.

DATA COLLECTION AND ANALYSIS

We collected data on primary and assisted primary patency rates (primary endpoints) as well as operating time, the length of hospital stay, limb salvage and local wound complications (secondary endpoints). We presented results as risk ratio or mean difference with 95% confidence intervals and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

No new studies were identified for this update. A single RCT with a total of 30 PAAs met the inclusion criteria. There was a low risk of selection bias and detection bias. However, the risks of performance bias, attrition bias and reporting bias were unclear from the study. Despite being an RCT, the certainty of the evidence was downgraded to moderate due to the small sample size, resulting in wide confidence intervals (CIs); only 30 PAAs were randomised over a period of five years (15 PAAs each in the groups receiving endovascular stent graft and undergoing conventional open surgery). The primary patency rate at one year was 93.3% in the endovascular group and 100% in the surgery group (RR 0.94, 95% CI 0.78 to 1.12; moderate-certainty evidence). The assisted patency rate at one year was similar in both groups (RR 1.00, 95% CI 0.88 to 1.13; moderate-certainty evidence). There was no clear evidence of a difference between the two groups in the primary or assisted patency rates at four years (13 grafts were patent from 15 PAA treatments in each group; RR 1.00, 95% CI 0.76 to 1.32; moderate-certainty evidence); the effects were imprecise and compatible with the benefit of either endovascular stent graft or surgery or no difference. Mean hospital stay was shorter in the endovascular group (4.3 days for the endovascular group versus 7.7 days for the surgical group; mean difference (MD) -3.40 days, 95% CI -4.42 to -2.38; P < 0.001; moderate-certainty evidence). Mean operating time was also reduced in the endovascular group (75.4 minutes in the endovascular group versus 195.3 minutes in the surgical group; MD -119.90 minutes, 95% CI -137.71 to -102.09; P < 0.001; moderate-certainty evidence). Limb salvage was 100% in both groups. Data on local wound complications were not published in the trial report.

AUTHORS' CONCLUSIONS

Evidence to determine the effectiveness of endovascular stent graft versus conventional open surgery for the treatment of asymptomatic PAAs is limited to data from one small study. At one year there is moderate-certainty evidence that primary patency may be improved in the surgery group but assisted primary patency rates were similar between groups. At four years there was no clear benefit from either endovascular stent graft or surgery to primary or assisted primary patency (moderate-certainty evidence). As both operating time and hospital stay were reduced in the endovascular group (moderate-certainty evidence), it may represent a viable alternative to open repair of PAA. A large multicenter RCT may provide more information in the future. However, difficulties in recruiting enough patients are likely, unless it is an international collaboration including a number of high volume vascular centres.

A Matched Case-Control Study on Open and Endovascular Treatment of Popliteal Artery Aneurysms

Objective:

To compare early and late results of open and endovascular management of popliteal artery aneurysm in a retrospective single-center matched case-control study

Methods:

From 1981 to 2015, 309 consecutive interventions for popliteal artery aneurysm were performed in our institution, in 59 cases with endovascular repair and in 250 cases with open repair. Endovascular repair was preferred in older asymptomatic patients, while open repair was offered more frequently to patients with a thrombosed popliteal artery aneurysm and a poor run-off status. A one-to-one coarsened exact matching on the basis of the baseline demographic, clinical, and anatomical covariates significantly different between the two treatment options was performed and two equivalent groups of 56 endovascular repairs and open repairs were generated. The two groups were compared in terms of perioperative results with χ2 test and of follow-up outcomes with the Kaplan–Meier curves and log-rank test.

Results:

There were no differences between the two groups in terms of perioperative outcomes. Median duration of follow-up was 38 months. Five-year survival rates were 94% in endovascular repair group and 89.5% in open repair group (p = 0.4, log-rank 0.6). Primary patency rates at 1, 3, and 5 years were 81%, 78%, and 72% in endovascular repair group and 82.5%, 80%, and 64% in open repair group (p = 0.8, log-rank 0.01). Freedom from reintervention at 5 years was 65.5% in endovascular repair group and 76% in open repair group (p = 0.2, log-rank 1.2). Secondary patency at 1, 3, and 5 years was 94%, 86%, and 74% in endovascular repair group, and 94%, 89%, and 71% in open repair group, respectively (p = 0.9, log-rank 0.01). The rates of limb preservation at 5 years were 94% in endovascular repair group and 86.4% in open repair group (p = 0.3, log-rank 0.8).

Conclusion:

Open repair and endovascular repair of popliteal artery aneurysms provided in this retrospective single-center experience similar perioperative and follow-up results in equivalent groups of patients.

Cardiovascular Risk Reduction is Important for Improving Patient and Graft Survival After Ligation and Bypass Surgery for Popliteal Artery Aneurysm

OBJECTIVES

To report outcomes following ligation and bypass (LGB) surgery for popliteal artery aneurysm (PAA) and study factors influencing patient and graft survival.

MATERIALS AND METHODS

A retrospective review of patients undergoing LGB surgery for PAA between September 1999 and August 2012 at a tertiary referral vascular unit was performed. Primary graft patency (PGP), primary-assisted graft patency (PAGP), and secondary graft patency (SGP) rates were calculated using survival analyses. Patient, graft aneurysm-free survival (GAFS), aneurysm reperfusion-free survival (ARFS), and amputation-free survival (AFS) rates were also calculated. Log-rank testing and Cox proportional hazards modeling were used to perform univariate and multivariate analysis of influencing factors, respectively.

RESULTS

Eighty-four LGB repairs in 69 patients (mean age 71.3 years, 68 males) were available for study. The 5-year PGP, PAGP, SGP, and patient survival rates were 58.1%, 84.4%, 85.2%, and 81.1%, respectively. On multivariate analysis, the principal determinants of PGP were urgency of operation ( P = .009) and smoking status ( P = .019). The principal determinants of PAGP were hyperlipidemia status ( P = .048) and of SGP were hyperlipidemia ( P = .042) and cerebrovascular disease (CVD) status ( P = .045). The principal determinants of patient survival were previous myocardial infarction ( P = .004) and CVD ( P = .001). The 5-year GAFS, ARFS, and AFS rates were 87.9%, 91.6%, and 96.1%, respectively.

CONCLUSION

This study has shown that traditional cardiovascular risk factors, such as a smoking and ischemic heart disease, are the most important predictors of early graft failure and patient death following LGB surgery for PAA.

Popliteal Artery Aneurysm Repair in the Endovascular Era: Fourteen-Years Single Center Experience

To compare outcomes of popliteal artery aneurysm (PAA) repair by endovascular treatment, great saphenous vein (GSV) bypass, and prosthetic bypass.Single center retrospective analysis of patients presenting PAA from 2000 to 2013. Patients were divided into endovascular treatment (group A); GSV bypass (group B); and prosthetic graft bypass (group C). Outcomes were technical success, perioperative mortality, and morbidity. Survival, primary and secondary patency, and freedom from reintervention rate were estimated. Differences in ankle-brachial index (ABI), in-hospital length of stay (InH-Los), red blood cell (RBC) transfusion, and limb loss were reported. Mean follow-up was 49 (median: 35; 1-145; SD 42) months.Sixty-seven patients were included; 25 in group A, 28 in group B, and 14 in group C. PAA was symptomatic in 23 (34%) cases. Technical success was 100%. No perioperative death occurred. Three (4.5%) perioperative complications were reported with no significant difference between groups (P = 0.866). Five-years estimated survival was 78%. Estimated 5-years primary patency for groups A, B, and C was 71%, 81%, and 69%, respectively (P = 0.19). Estimated 5-years secondary patency for groups A, B, and C was 88%, 85%, and 84% (P = 0.85). Estimated 5-years freedom from reintervention for groups A, B, and C was 62%, 84%, and 70%, respectively (P = 0.16). A significant difference between preoperative ABI versus postoperative ABI was observed (P = 0.001). InH-LoS was significantly shorter in group A (P < 0.001). RBC transfusions were required significantly less in group A when compared to group C (P = 0.045). Overall limb salvage was achieved in all but 1 patient.PAA repair has good early and long-term outcomes with different treatment options. Endovascular treatment was not inferior to surgical repair with a reduced InH-LoS and RBC transfusion. It can be successfully employed even in nonelective setting. A randomized controlled trial with long-term follow-up and appropriate patient inclusion criteria is necessary to compare these 3 treatment options.

A Systematic Review and Meta-analysis of Endovascular Popliteal Aneurysm Repair Using the Hemobahn/Viabahn Stent-Graft

Purpose: To perform an evidence synthesis study to assess outcomes of endovascular repair of popliteal artery aneurysms (PAAs) using the Hemobahn or Viabahn stent-graft. Methods: A systematic literature review was conducted conforming to established standards to identify articles published between 1996 (the date of introduction of the Hemobahn stent-graft) and 2013 reporting stent-graft repair of PAAs in at least 10 patients. The data were pooled for Kaplan-Meier analysis of primary and secondary patency rates [presented with 95% confidence intervals (CIs)] as the primary outcomes. Random effects meta-analysis was performed for secondary outcomes that included rates of reintervention, endoleak, stent-graft fracture, and limb salvage. Results: Fourteen studies reported outcomes for 514 PAAs. There was considerable heterogeneity in reporting standards among studies. Pooled primary and secondary patency rates were 69.4% (95% CI 63.3% to 76.2%) and 77.4% (95% CI 70.1% to 85.3%), respectively, at 5 years. Five studies (including only one randomized controlled trial) compared surgical to endovascular repair; no difference was found in primary patency on evidence synthesis (hazard ratio 1.30, 95% CI 0.79 to 12.14, p=0.189). Conclusion: Stent-graft repair provides a feasible treatment option for anatomically suitable PAAs. Further studies are required to optimize both patient selection and follow-up protocols.

Access and hemostasis: femoral and popliteal approaches and closure devices-why, what, when, and how?

This article reviews the arterial access sites used in the treatment of peripheral arterial disease, including common femoral, superficial femoral, and popliteal arterial puncture. The optimal approach and techniques for arterial puncture will be described and technical tips and tricks will be discussed. An overview of the currently available vascular closure devices will also be presented. Indications, contraindications, and complications will be discussed. Results of the use of vascular closure devices compared with manual compression will be presented.

Endovascular versus open repair of asymptomatic popliteal artery aneurysm

BACKGROUND

Popliteal artery aneurysm (PAA) is a focal dilatation and weakening of the popliteal artery. If left untreated, the aneurysm may thrombose, rupture or the clot within the aneurysm may embolise causing severe morbidity. PAA may be treated surgically by performing a bypass from the arterial segment proximal to the aneurysm to the arterial segment below the aneurysm, which excludes the aneurysm from the circulation. It may also be treated by a stent graft that is inserted percutaneously or through a small cut in the groin. The success of the procedure is gauged by the ability of the graft to stay patent over an extended duration. While surgical treatment is usually preferred in an emergency, the evidence on first line treatment in a non-emergency setting is unclear.

OBJECTIVES

To assess the effectiveness of an endovascular stent graft versus conventional open surgery for the treatment of asymptomatic popliteal artery aneurysms (PAA) on primary and assisted patency rates, hospital stay, length of the procedure and local complications.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched their Specialised Register (last searched June 2014) and CENTRAL (2014, Issue 5). Clinical trials databases were searched for any ongoing or unpublished studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing endovascular stent grafting versus conventional open surgical repair in patients undergoing unilateral or bilateral prophylactic repair of asymptomatic PAAs were included.

DATA COLLECTION AND ANALYSIS

Data were collected on primary and secondary patency rates (primary endpoints) as well as operating time, the length of hospital stay, limb salvage and local wound complications (secondary endpoints).

MAIN RESULTS

A single RCT was identified that conformed to the inclusion criteria. There was a low risk of selection bias and detection bias. However, the risks of performance bias, attrition bias and reporting bias were unclear from the study. Despite being an RCT, the level of evidence was downgraded to moderate due to the small sample size, resulting in wide confidence intervals (CIs); only 30 PAAs were randomised over a period of five years (15 PAAs each in the groups receiving endovascular stent graft and undergoing conventional open surgery). The primary patency rate at one year was 100% in the surgery group and 93.3% in the endovascular group (P = 0.49). However, the assisted patency rate at one year was similar in both groups (100% patency). There was no clear evidence of a difference between the two groups in the primary or secondary patency rates at four years (13 grafts were patent from 15 PAA treatments in each group). However, the effects were imprecise and compatible with the benefit of either endovascular stent graft or surgery or no difference. Mean hospital stay was shorter in the endovascular group (4.3 days for the endovascular group versus 7.7 days for the surgical group; mean difference (MD) -3.40 days, 95% CI -4.42 to -2.38; P < 0.001). Mean operating time was also reduced in the endovascular group (75.4 minutes in the endovascular group versus 195.3 minutes in the surgical group; MD -119.20 minutes, 95% CI -137.71 to -102.09; P < 0.001). Limb salvage was 100% in both groups. Data on local wound complications were not published in the trial report.

AUTHORS' CONCLUSIONS

Due to the limitations of the current evidence from one small underpowered study, we are unable to determine the effectiveness of endovascular stent graft versus conventional open surgery for the treatment of asymptomatic PAAs. A larger ongoing multicentre RCT should provide more information in the future. However, it seems reasonable to suggest that endovascular repair should be considered as a viable alternative to open repair of PAA on a case by case basis.

Cryopreserved autologous saphenous vein for staged treatment of bilateral popliteal aneurysms: report of three cases

Popliteal artery aneurysms are the most common aneurysmal disease of the lower extremity. Although endovascular solutions are gaining consensus, open surgery with interposition grafting remains the standard of care. The great saphenous vein (GSV) is the most commonly used conduit and shows the best long-term results. However, optimal vein segments can sometimes be unavailable, thus leading to the use of unsuitable segments or prosthetic grafts. We report the cases of 3 patients who had bilateral popliteal aneurysms and only 1 GSV that was considered suitable for grafting, without alternative venous segments. All patients underwent staged treatment with the use of the GSV. After the first operation, the remaining GSV was cryopreserved and then reused for the contralateral limb. All patients had an uneventful outcome. No graft occlusions and no aneurysmal dilatations were detected at follow-up. Cryopreservation of autologous vein for staged treatment of bilateral popliteal aneurysms is feasible and seems to avoid the risk of residual GSV loss during the time inbetween the interventions.

Hygroma following endovascular femoral aneurysm exclusion: A case report

INTRODUCTION

Endovascular treatment of aneurysms in the superficial femoral artery (SFA) and popliteal segments is a suggested alternative to open surgical repair. Careful selection of patients for endovascular treatment of SFA aneurysms is mandatory.

PRESENTATION OF CASE

A complication due to endovascular stent-graft treatment in an 80-year old male with a 6 cm aneurysm in the SFA is presented. Hygroma developed after a partially unintended extravascular placed stent-graft. Two consecutive explorations resulted in a femoro-popliteal Polytetrafluoro-ethylene (PTFE) by-pass graft as the final solution.

DISCUSSION

Several explanations for the patient's complications are suggested.

CONCLUSION

A primary femoral-femoral/popliteal by-pass might be the best solution in SFA aneurysms due to risk of stent complications.

Results of elective and emergency endovascular repairs of popliteal artery aneurysms

OBJECTIVE

Endovascular repair has emerged as a treatment option for popliteal artery aneurysms. Our goal was to analyze outcomes of elective and emergency endovascular popliteal artery aneurysm repair (EVPAR).

METHODS

This was a retrospective review of clinical data of patients treated with EVPAR at our institution between 2004 and 2010. Stent-related complications, patency, outcome limb salvage, and survival were evaluated and analyzed.

RESULTS

EVPAR was performed in 31 limbs of 25 patients (mean age, 81 years; range, 65-89 years). Repair was elective in 19 limbs (61%) and emergent in 12 (39%). One aneurysm ruptured and 11 presented with acute thrombosis. All 11 underwent thrombolysis before EVPAR. Patients were implanted with a mean of 2.1 Viabahn stent grafts (range, 1-4). Ten procedures (32%) were performed percutaneously and 21 by femoral cutdown. Technical success was 97%. Overall 30-day mortality was 6.4%, with 0% in the elective group, and 16.7% in the emergent group (P = .14). Early complications included graft thrombosis in two limbs (6.4%) and hematoma in four (13%), all after percutaneous repair. Myocardial infarction and thrombolysis-associated intracranial hemorrhage occurred in one patient each (3.2%). The 30-day primary and secondary patencies were 93.6% and 96.7%, respectively, and were 100% in the elective group and 83.3% and 91.6%, respectively, for the emergent group. Mean follow-up was 21.3 months (range, 1-75 months). Primary patency at 1 year was 86% (95% for elective, 69% for emergent; P = .56), secondary patency at the same time was 91% (elective, 100%; emergent, 91%). One-year limb salvage was 97%. Two-year survival was 91% for the elective group and 73% for the emergent group (P = .15). Five stent occlusions were encountered after 30 days, four in the elective group. Four underwent successful reintervention, two had bypass, and two had thrombolysis, followed by angioplasty. The fifth patient was asymptomatic and nonambulatory and remains under observation. Stent graft infolding occurred in one limb (3.2%), with no clinical sequelae. No stent migration or separation was observed. One stent fracture was noted in an asymptomatic patient. Three (10%) type II endoleaks were detected but none had aneurysm expansion. One (3.2%) type I endoleak was treated percutaneously with placement of an additional stent graft. Overall, major adverse events, including death, graft occlusion with or without reoperation, or reoperation for endoleak or stent infolding occurred after 11 procedures (35.5%). On univariate analysis, no factors predicted stent failure, including runoff, antiplatelet therapy, emergency repair, number of stents implanted, heparin bonding of the stent, or degree of stent oversizing.

CONCLUSIONS

These results support elective EVPAR in anatomically suitable patients with increased risk for open repair; however, major adverse events after EVPAR, mainly after emergency repairs, are frequent. A prospective randomized multicenter study to justify EVPAR in the emergent setting is warranted.