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Ng NZP, Pang JHQ, Yap CJQ, Chao VTT, Tay KH, Chong TT. Custom-Made Device (CMD) for the Repair of Thoraco-Abdominal Aneurysm (TAA): Mid-Long Term Outcomes from a Single Southeast Asian Centre Experience in Singapore. J Clin Med 2024; 13:6145. [PMID: 39458095 PMCID: PMC11508193 DOI: 10.3390/jcm13206145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2024] [Revised: 10/04/2024] [Accepted: 10/12/2024] [Indexed: 10/28/2024] Open
Abstract
Introduction: Given the high risk of peri-operative morbidity and mortality associated with open repair, endovascular repair for thoraco-abdominal aneurysms is increasingly performed. This study aims to describe mid to long-term results for patients who were treated with COOK Custom-Made Endograft Device at a single Southeast Asian tertiary centre. Methods: Mid to long-term results of patients treated from 2012 to 2022 were retrospectively reviewed. Indications for treatment were aortic diameter > 5.5 cm, enlargement > 5 mm in 6 months or high-risk morphology. Clinical, operative, early to late complications and reintervention details were captured. The endpoints were technical success, primary patency and primary assisted patency. Results: Electronic medical records of 29 consecutive patients (64.4 ± 1.6 years old; 26/29 males 89.6%) were reviewed. 24/29 (83%) were hypertensive, and 20/29 (69%) were smokers. The mean diameter was 5.5 cm, and the majority were treated for Crawford type IV (19/29, 65.5%). Endograft deployment was 100%. Catheterisation of fenestration was successful in 109/116 (94%). 30-day mortality and morbidity were observed in 12/29 (41%), for which access site complications were most common. No significant haemorrhage or graft explant was recorded. The mean follow-up period was 32.4 months (range 1-108 months). Primary patency was 92.9% (95% CI: 83.8-100.0) at 6 months and decreased to 77.7% (95% CI: 63.4-95.2) at 24 months. Sac shrinkage or stability was noted in 17/29 (58.6%). Re-intervention was performed in 9/29 (31%) for limb occlusion (2/9, 22.2%), renal artery stent occlusion (1/9, 11.1%) and endoleaks (6/9, 66.6%). Assisted patency was maintained at 100% for 12 months before decreasing to 66.7% (95% CI: 37.9-100.0) at 24 months. Conclusions: The study reports the first mid-long-term result in this region, though limited by the sample size. Re-intervention at 30% suggests that disease and procedures remain challenging, emphasising the need to assimilate lessons and experience at high-volume centres.
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Affiliation(s)
- Nick Zhi Peng Ng
- Department of Vascular Surgery, Singapore General Hospital, Outram Road, Singapore 169856, Singapore
| | - Jolyn Hui Qing Pang
- Department of Vascular Surgery, Singapore General Hospital, Outram Road, Singapore 169856, Singapore
| | - Charyl Jia Qi Yap
- Department of Vascular Surgery, Singapore General Hospital, Outram Road, Singapore 169856, Singapore
| | - Victor Tar Toong Chao
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, 5 Hospital Drive, Singapore 169609, Singapore
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore 169856, Singapore
| | - Kiang Hiong Tay
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore 169856, Singapore
- Duke-NUS Graduate Medical School, 8 College Road, Singapore 169857, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Outram Road, Singapore 169856, Singapore
- Duke-NUS Graduate Medical School, 8 College Road, Singapore 169857, Singapore
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Piffaretti G, Zammito A, Guzzetti L, Selmo G, Binda S, D'Onofrio D, Tozzi M, Franchin M. Outcome analysis of the surgical team in open surgical repair of intact abdominal aortic aneurysm surgery. Eur J Cardiothorac Surg 2024; 66:ezae319. [PMID: 39186003 DOI: 10.1093/ejcts/ezae319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 08/09/2024] [Accepted: 08/22/2024] [Indexed: 08/27/2024] Open
Abstract
OBJECTIVES To analyze how the experience of the surgical team went to impact the outcomes after open surgical repair (OSR) of intact abdominal aortic aneurysms (AAAs). METHODS This is a single-center, observational cohort study with retrospective analysis of all OR for intact AAA performed between 1 January 2010 and 31 December 2022. The primary outcome was survival at 30 days and in follow-up, and a composite outcome of mortality and major complication. The secondary outcome was freedom from aorta-related reintervention. All outcomes were stratified according to the experience of the operating team (surgeons and anesthesiology). RESULTS We analyzed 103 (7.2%) patients: 97 (94.2%) males and 6 (5.8%) females. The mean age was 76 ± 8 years (range, 55-93). The best possible team composition was present in 52 (50.5%) interventions. The follow-up index was 0.82 ± 0.18 (range, 0.6-1.0). Mean follow-up duration was 59 ± 43 months (range, 0-158). We observed no differences between teams in major complications (best, 17.3% vs mixed, 21.6%; OR: 0.4, P = 0.622), 30 days mortality (best, 0% vs mixed, 5.9%; OR: 7.6, P = 0.118) and composite outcome (best, 11.5% vs mixed, 17.6%; OR: 0.8, P = 0.416). Cox regression analysis identified the best possible team as a protective factor against the need for reintervention (hazard ratio: 0.2; 95% confidence interval: 0.06-0.88, P = 0.032). CONCLUSIONS In our experience, OR of AAA yielded satisfactory results in terms of safety and efficacy independently of the team's experience. A more experienced team may protect against aorta-related reintervention.
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Affiliation(s)
- Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine and ASST Settelaghi University Teaching Hospital, Varese, Italy
| | - Alessandro Zammito
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine and ASST Settelaghi University Teaching Hospital, Varese, Italy
| | - Luca Guzzetti
- Anesthesia and Palliative Care, ASST Settelaghi University Teaching Hospital, Varese, Italy
| | - Gabriele Selmo
- Anesthesia and Palliative Care, ASST Settelaghi University Teaching Hospital, Varese, Italy
| | - Simone Binda
- Anesthesia and Palliative Care, ASST Settelaghi University Teaching Hospital, Varese, Italy
| | - Dunia D'Onofrio
- Anesthesia and Palliative Care, ASST Settelaghi University Teaching Hospital, Varese, Italy
| | - Matteo Tozzi
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine and ASST Settelaghi University Teaching Hospital, Varese, Italy
| | - Marco Franchin
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine and ASST Settelaghi University Teaching Hospital, Varese, Italy
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Koleilat I, Dalmia V, Batarseh P, Rai A, Carnevale M, Phair J, Indes J. Large-Diameter Fenestrated Endograft Repair of Abdominal Aortic Aneurysms Is Not Associated With Medium-Term Outcomes. J Surg Res 2024; 296:516-522. [PMID: 38330677 DOI: 10.1016/j.jss.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 12/11/2023] [Accepted: 01/15/2024] [Indexed: 02/10/2024]
Abstract
INTRODUCTION Recent data suggests that infrarenal abdominal aortic aneurysm (AAA) endovascular repair (EVAR) with large diameter grafts (LGs) may have a higher risk of endoleak and reintervention. However, this has not been studied extensively for fenestrated endovascular aneurysm repair (fEVAR). We, therefore, sought to evaluate the outcomes of patients undergoing fEVAR with large-diameter endografts. METHODS Patients from the national Vascular Quality Initiative registry who underwent fEVAR for intact juxtarenal AAA were identified. Patients with genetic causes for aneurysms, those with prior aortic surgery, and those undergoing repair for symptomatic or ruptured aneurysms were excluded. Rates of endoleaks and reintervention at periprocedural and long-term follow-up timepoints (9-22 mo) were analyzed in grafts 32 mm or larger (LG) and were compared to those smaller than 32 mm (small diameter graft). RESULTS A total of 693 patients (22.8% LG) were identified. Overall, demographic variables were comparable except LG exhibited a more frequent history of coronary artery disease (32.9% versus 25.4%, P = 0.037). There were no significant differences in the rates of endoleak at procedural completion. Overall survival at 5 y was no different. The rate of reintervention at 1 y was also no different (log-rank P = 0.86). CONCLUSIONS While graft size appears to have an association with outcomes in infrarenal aneurysm repair, the same does not appear to be true for fEVAR. Further studies should evaluate the long-term outcomes associated with LG which could alter the approach to repair of AAA with large neck diameters traditionally treated with standard infrarenal EVAR.
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Affiliation(s)
- Issam Koleilat
- Department of Surgery, Community Medical Center, RWJ/Barnabas Health, Toms River, New Jersey.
| | - Varun Dalmia
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Paola Batarseh
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Anvit Rai
- Division of Vascular and Endovascular Surgery, Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Matthew Carnevale
- Division of Vascular and Endovascular Surgery, Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - John Phair
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeff Indes
- Division of Vascular and Endovascular Surgery, Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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Bertrand L, Prendes CF, Melo R, Tsilimparis N, Bacharach T, Dayama A, Stana J, Rantner B. Impact of Previous Open Abdominal Surgery on Open Abdominal Aortic Repair: A Study from the NSQIP Database. Ann Vasc Surg 2024; 99:380-388. [PMID: 37914074 DOI: 10.1016/j.avsg.2023.09.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/27/2023] [Accepted: 09/04/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND While endovascular aneurysm repair has become a first-line strategy in many centers, open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) is still the best option for certain patients. A significant number of patients who are offered OSR for AAA have been previously submitted to other open abdominal surgeries (PAS). It is unclear, however, how this may impact their outcomes. The purpose of this study was to determine if there is an association between PAS and outcomes of OSR of AAA. METHODS This is a retrospective cohort study based on clinical data from the American College of Surgeons National Surgical Quality Improvement Program database, including all patients undergoing elective OSR for AAA between 2011 and 2017. Excluded were patients with missing data on prior abdominal surgery, supramesenteric clamping, or urgent repairs. Patients with prior abdominal surgery (PAS) and patients without prior abdominal surgeries (nonPAS) were compared. The primary outcome was 30-day postoperative mortality. Secondary outcomes were operating time, ischemic colitis, postoperative complications, and lengths of hospital stay. RESULTS Of the 2034 patients included, 27% had previous open abdominal surgery and 73% did not. Overall, the median age was 71(interquartile range 65-76), 72% of patients were male, 44% were smokers, and the average body mass index was 27 kg/m2. Univariate analysis showed no difference in postoperative 30-day mortality (4.0% PAS vs. 4.1% nonPAS, P = 0.91) or overall postoperative complication rates (33% PAS vs. 29% nonPAS, P = 0.07). Previous open abdominal surgery was significantly associated with longer operating times (P = 0.032) and an almost doubled rate of ischemic colitis (4.7% PAS vs. 2.6% nonPAS, P = 0.02). Postoperative intensive care unit and hospitalization were also significantly longer in patients with prior abdominal surgery (P = 0.005 and P = 0.014, respectively). Finally, there were significantly less patients discharged home, as opposed to institutionalized care (75.7% PAS down from 82.4% nonPAS, P = 0.001). Despite these initial univariate analysis results, on multivariate analysis, PAS actually did not prove to be a statistically significant independent risk factor for 30-day mortality, ischemic colitis, or longer operating times. CONCLUSIONS This study suggests that patients who have undergone PAS may have some disadvantages in OSR of AAA. However, these negative trends do not go so far as to statistically significantly identify PAS as an independent risk factor for 30-day mortality, ischemic colitis, or longer operating times. As such, we suggest that a history of previous open abdominal surgery, in and of its own, should not exclude patients from consideration for open aortic abdominal aneurysm repair.
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Affiliation(s)
- Laurence Bertrand
- Department of Vascular Surgery, Ludwig Maximillian University Hospitals, München, Germany.
| | | | - Ryan Melo
- Department of Vascular Surgery, Ludwig Maximillian University Hospitals, München, Germany
| | - Nikolas Tsilimparis
- Department of Vascular Surgery, Ludwig Maximillian University Hospitals, München, Germany
| | - Thekla Bacharach
- Department of Vascular Surgery, Ludwig Maximillian University Hospitals, München, Germany; Sanford USD Medical Centre and Hospital, Sioux Falls, SD
| | - Anand Dayama
- Department of Vascular Surgery, Ludwig Maximillian University Hospitals, München, Germany; Sanford USD Medical Centre and Hospital, Sioux Falls, SD
| | - Jan Stana
- Department of Vascular Surgery, Ludwig Maximillian University Hospitals, München, Germany
| | - Barbara Rantner
- Department of Vascular Surgery, Ludwig Maximillian University Hospitals, München, Germany
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Kargul M, Skórka P, Gutowski P, Kazimierczak A, Wiernicki I, Rynio P. Beyond Diameter: Enhancing Abdominal Aortic Aneurysm Surveillance with Volumetric Assessments after Endovascular Aneurysm Repair (EVAR). J Clin Med 2023; 12:6733. [PMID: 37959199 PMCID: PMC10648027 DOI: 10.3390/jcm12216733] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/22/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
This study aimed to investigate the relationship between maximum transverse diameter (MTD) and volume measurements in patients who underwent reoperations after endovascular aneurysm repair (EVAR), and their association with the occurrence of endoleaks. The study included 51 patients who underwent EVAR and subsequent re-operations caused by endoleaks type I-III. In some number of events, multiple re-operations were needed. MTD was measured using the Horos software, and segmentations of the AAA were performed using 3D Slicer. This study first evaluated post-operative computed tomography angiography (CTA) to measure MTD and volume. Then, similar measurements were made in the control scan for re-operation qualification. Negative remodeling (increase in MTD and/or volume) was observed in 40 cases using MTD, and 48 cases using volume measurements. The volume measurement showed lower missed negatives than MTD, indicating its effectiveness in screening for negative remodeling (p < 0.001). Combining both methods identified 51 negative remodeling cases and 8 positive changes, with a higher sensitivity compared to MTD alone. The volume of the sac did not predict specific endoleak types. Decreases in MTD were observed in smaller sacs, with smaller volume changes. Volume measurement is a valuable screening tool, and combining MTD and volume enhances sensitivity. However, sac volume does not predict endoleak type.
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Affiliation(s)
- Michał Kargul
- Department of Vascular Surgery, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland (I.W.)
| | | | | | | | | | - Paweł Rynio
- Department of Vascular Surgery, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland (I.W.)
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6
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Waldeck S, Overhoff D, Brockmann MA, Becker BV. Detection of Endoleaks Following Thoracic and Abdominal Aortic Endovascular Aortic Repair-: A Comparison of Standard and Dynamic 4D-Computed Tomography Angiography. J Endovasc Ther 2023; 30:739-745. [PMID: 35582987 DOI: 10.1177/15266028221095390] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Endoleaks are a common complication after endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR). The detection and correct classification of endoleaks is essential for the further treatment of affected patients. However, standard computed tomography angiography (CTA) provides no hemodynamic information on endoleaks, which can result in misclassification in complex cases. The aim of this study was to compare standard CTA (sCTA) with dynamic, dual-energy CTA (dCTA) for detection and classification of endoleaks following EVAR or TEVAR. MATERIALS AND METHODS This retrospective evaluation compared 69 sCTA diagnostic examinations performed on 50 different patients with 89 dCTA diagnostic examinations performed on 69 different patients. RESULTS In total, 15.9% of sCTA examinations and 49.4% of dCTA examinations led to the detection of endoleaks. With sCTA, 20.0% of patients were diagnosed with endoleaks, while with dCTA, 37.7% of patients were diagnosed with endoleaks. With sCTA, mainly Type 1 endoleaks were detected, whereas, with dCTA, the types of detected endoleaks were more evenly distributed. In comparison with the literature, the frequencies of endoleak types detected with dCTA better reflect the natural distribution than the frequencies detected with standard CTA. CONCLUSION Based on the retrospective comparative evaluation, dCTA could pose a valuable supplementary diagnostic tool resulting in a more accurate and realistic detection and classification of suspected endoleaks.
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Affiliation(s)
- Stephan Waldeck
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
- Institute of Neuroradiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Daniel Overhoff
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marc A Brockmann
- Institute of Neuroradiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Benjamin V Becker
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
- Institute of Neuroradiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
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Lenzini L, Caroccia B, Seccia TM, Rossi GP. Peptidergic G Protein-Coupled Receptor Regulation of Adrenal Function: Bench to Bedside and Back. Endocr Rev 2022; 43:1038-1050. [PMID: 35436330 DOI: 10.1210/endrev/bnac011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Indexed: 11/19/2022]
Abstract
An altered secretion of adrenocortical and adrenomedullary hormones plays a role in the clinical syndromes of primary aldosteronism (PA), Cushing, and pheochromocytoma. Moreover, an altered production of adrenocortical hormones and/or an abnormal release of factors by the adrenal medulla are involved in several other diseases, including high blood pressure, congestive heart failure, liver cirrhosis, nephrotic syndrome, primary reninism, renovascular hypertension, Addison disease, Bartter, Gitelman, and virilization syndromes. Understanding the regulation of adrenal function and the interactions between adrenal cortex and medulla is, therefore, the prerequisite for mechanistic understanding of these disorders. Accumulating evidence indicates that the modulation of adrenal hormone biosynthesis is a process far more complex than originally thought, as it involves several factors, each cooperating with the other. Moreover, the tight vascular and neural interconnections between the adrenal cortex and medulla underlie physiologically relevant autocrine/paracrine interactions involving several peptides. Besides playing a pathophysiological role in common adrenal diseases, these complex mechanisms could intervene also in rare diseases, such as pheochromocytoma concomitant with adrenal Cushing or with PA, and PA co-occurring with Cushing, through mechanisms that remain to be fully understood at the molecular levels. Heterodimerization of G protein-coupled receptors (GPCRs) induced by peptide signaling is a further emerging new modulatory mechanism capable of finely tuning adrenal hormones synthesis and release. In this review we will examine current knowledge on the role of peptides that act via GPCRs in the regulation of adrenal hormone secretion with a particular focus on autocrine-paracrine signals.
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Affiliation(s)
- Livia Lenzini
- Emergency Medicine Unit, Center for blood pressure disorders -Regione Veneto and Specialized Center of Excellence for Hypertension of the European Society of Hypertension, Department of Medicine-DIMED, University of Padua, 35126 Padua, Italy
| | - Brasilina Caroccia
- Emergency Medicine Unit, Center for blood pressure disorders -Regione Veneto and Specialized Center of Excellence for Hypertension of the European Society of Hypertension, Department of Medicine-DIMED, University of Padua, 35126 Padua, Italy
| | - Teresa Maria Seccia
- Emergency Medicine Unit, Center for blood pressure disorders -Regione Veneto and Specialized Center of Excellence for Hypertension of the European Society of Hypertension, Department of Medicine-DIMED, University of Padua, 35126 Padua, Italy
| | - Gian Paolo Rossi
- Emergency Medicine Unit, Center for blood pressure disorders -Regione Veneto and Specialized Center of Excellence for Hypertension of the European Society of Hypertension, Department of Medicine-DIMED, University of Padua, 35126 Padua, Italy
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Cherfan P, Abdul-Malak OM, Liang NL, Eslami MH, Singh MJ, Makaroun MS, Chaer RA. Endovascular repair of abdominal and thoracoabdominal aneurysms using chimneys and periscopes is associated with poor outcomes. J Vasc Surg 2022; 76:311-317. [PMID: 35276255 PMCID: PMC10804879 DOI: 10.1016/j.jvs.2022.02.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/27/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Chimneys and periscopes are often used to treat pararenal or thoracoabdominal aneurysms de novo or after failed open or endovascular repair. We sought to describe our institutional experience, given their limited success and questionable long-term outcomes. METHODS We retrospectively reviewed the electronic records for patients treated with chimneys/periscopes from 1997 through 2020. Baseline characteristics, procedural details, periprocedural complications, reinterventions, and midterm outcomes were collected. RESULTS Fifty-eight patients (86 vessels) were treated; the median follow-up was 32 months (range, 0.03-104 months). There were 36% (n = 21) juxta-renal, 2% (n = 1) para-visceral, and 21% (n = 12) thoracoabdominal aneurysms, and 41% (n = 24) had pararenal failure of prior endovascular aneurysm repair (n = 17) or open repair (n = 7). Stent configuration for the majority of the 86 vessels (n = 80; 93%) treated were chimney configuration (n = 6 periscopes; 7%). The most common stent graft utilized was Viabahn, and 8.1% (n = 7) were reinforced with a bare metal stent. Although the majority of the cases were elective, 36.2% (n = 21) of the cases were urgent/emergent. At the conclusion of the initial procedure, 16 of 58 patients had an endoleak (gutter, 50% [8/16]; type Ia, 25% [4/16]; and type II, 25% [4/16]). On follow-up, 14 of 58 patients developed one or more endoleaks, with the most common endoleaks being a gutter endoleak (35% [7/20]). Other endoleaks observed included 30% (6/20) type III, 15% (3/20) type Ia, 15% (3/20) type Ib, and 5% (1/20) type II. Eleven of 58 patients underwent interventions for one or more endoleak (gutter, 33% [5/15]; type Ib, 20% [3/15]; type II, 7% [1/15]; and type III, 40% [6/15]). Twelve of 58 patients returned to the operating room for one or more procedures during the index hospitalization (five laparotomies, three dialysis access, three acute limb ischemia, and four chimney/periscope interventions). Ten of 58 patients underwent angioplasty/stenting for chimney/periscope compression or occlusion during the follow-up period. Survival was 61.3% at 1 year by Kaplan-Meier analysis (75% for elective, 37% for urgent/emergent) (aneurysm-related death, 22%). Cox hazard modeling showed that aneurysm diameter (hazard ratio, 1.03; 95% confidence interval, 1.004-1.05; P = .02) and urgent/emergent interventions (hazard ratio, 3.6; 95% confidence interval, 1.33-9.74; P = .01) were predictors of mortality. CONCLUSIONS Endovascular repair of aortic aneurysms with chimneys/periscopes is associated with poor outcomes, including limited technical success and aneurysm exclusion, as well as high morbidity and mortality, with a high rate of reinterventions both in the immediate postoperative period and on follow-up. They should be used only when other surgical or endovascular options are not possible.
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Affiliation(s)
- Patrick Cherfan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Othman M Abdul-Malak
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Michael J Singh
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Rastogi V, Kim NH, Marcaccio CL, Patel PB, Varkevisser RRB, de Bruin JL, Verhagen HJM, Schermerhorn ML. Retroperitoneal versus Transperitoneal Approach for Open Repair of Complex Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2022; 64:23-31. [PMID: 35605910 PMCID: PMC9420765 DOI: 10.1016/j.ejvs.2022.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 05/03/2022] [Accepted: 05/14/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Several studies have demonstrated advantages of the retroperitoneal approach (RP) over the transperitoneal approach (TP) for infrarenal abdominal aortic aneurysm (AAA) repair. A retrospective analysis was performed comparing the outcomes of a TP vs. RP surgical approach for open complex AAA (cAAA) repair and evaluated their relative use over time. METHODS Patients undergoing open repair for intact cAAA (juxtarenal, suprarenal, or type IV thoraco-abdominal aortic aneurysms) between 2011 and 2019 were identified in the National Surgical Quality Improvement Program. The primary outcome was peri-operative death. Secondary outcomes included peri-operative complications and approach use over time. Multivariable adjustment was performed by creating propensity scores and using inverse probability weighted logistic regression. RESULTS Among 1 195 patients identified, 729 (61%) underwent cAAA repair via a TP approach and 466 (39%) via an RP approach. Compared with a TP approach, RP patients more frequently had a supracoeliac clamp position (32% vs. 20%, p < .001) and concomitant renal revascularisation (30% vs. 18%, p < .001). After adjustment, an RP approach was associated with lower odds of peri-operative death (4.0% vs. 7.2%; odds ratio [OR] 0.54; 95% confidence interval [CI] 0.32 - 0.91; p = .022). Furthermore, an RP approach was associated with lower odds of any major complication (24% vs. 30%; OR 0.73; 95% CI 0.56 - 0.94), cardiac complications (4.9% vs. 8.2%; OR 0.60; 95% CI 0.37 - 0.96), wound complications (2.1% vs. 6.0%; OR 0.34; 95% CI 0.17 - 0.64), and post-operative sepsis (0.8% vs. 2.4%; OR 0.37; 95% CI 0.12 - 0.99). The proportion of repairs using an RP approach decreased between 2011 - 2015 and 2016 - 2019 (42% vs. 35%, p = .020), particularly for suprarenal and type IV thoraco-abdominal aneurysms (49% vs. 37%, p = .023). CONCLUSION In open cAAA repair, the RP approach may be associated with lower peri-operative mortality and morbidity rates compared with the TP approach. However, it was found that the relative use of the RP approach is decreasing over time, even in suprarenal/type IV thoraco-abdominal aneurysms, and repairs using a supracoeliac clamp. Increased use of the RP approach, when appropriate, may lead to improved outcomes following open cAAA repair.
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Affiliation(s)
- Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA; Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Nicole H Kim
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Priya B Patel
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Rens R B Varkevisser
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA.
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10
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"Large Diameter" Aortic Endografts Are Associated With Aneurysm Sac Expansion. Ann Vasc Surg 2022; 87:225-230. [PMID: 35595204 DOI: 10.1016/j.avsg.2022.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION/OBJECTIVES The purpose of this study was to evaluate the association between aortic endograft diameter and long-term outcomes following endovascular aneurysm repair (EVAR) performed in accordance with manufacturer instructions for use (IFU). METHODS Retrospective review of consecutive patients undergoing on-IFU EVAR (2000-2018) was performed to facilitate a comparative analysis of long-term patient outcomes based on device diameter. "Large diameter" devices were defined as >34mm. The primary outcome of interest was freedom from sac expansion throughout long-term follow-up. Analyses included standard bivariate analyses, Kaplan Meier with log-rank comparison, and Cox proportional hazards multivariate analysis. RESULTS A total of 1099 underwent on-IFU EVAR from 2000-2018. Follow-up data were available for 980 patients. Of these, 75 patients (7.6%) were treated with >34 mm devices. There were no significant differences in demographics or co-morbidities between the 2 groups, although pre-operative AAA size was greater in patients undergoing implantation of >34mm devices (58 ± 8.5 mm vs. 56 ± 17.4 mm; P=0.05). Median follow-up was 10.3 years. Patients with grafts >34 mm had reduced freedom from sac expansion throughout follow-up (P=0.038). There were no significant differences in reintervention rates, open conversion, or rupture when stratified by graft diameter. Multivariate Cox Regression identified patient age, pre-operative AAA size, need for reintervention, and use of >34 mm endografts as independent factors associated with expansion. CONCLUSION The use of large diameter aortic endografts is associated with higher rates of sac expansion during long-term follow-up. While there is undoubtedly a role for large diameter graft use in selected patients, it is important to recognize that these devices were typically approved post-hoc without the same regulatory scrutiny of smaller endografts. These findings underscore the importance of ongoing surveillance for patients treated with >34 mm grafts, irrespective of compliance with manufacturer IFU.
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11
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van Rijswijk RE, Groot Jebbink E, Holewijn S, Stoop N, van Sterkenburg SM, Reijnen MMPJ. Predictors of Abdominal Aortic Aneurysm Shrinkage after Endovascular Repair. J Clin Med 2022; 11:jcm11051394. [PMID: 35268486 PMCID: PMC8910935 DOI: 10.3390/jcm11051394] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 02/01/2023] Open
Abstract
Recent studies demonstrate that patients with a shrinking abdominal aortic aneurysm (AAA), one-year after endovascular repair (EVAR), have better long-term outcomes than patients with a stable AAA. It is not known what factors determine whether an AAA will shrink or not. In this study, a range of parameters was investigated to identify their use in differentiating patients that will develop a shrinking AAA from those with a stable AAA one-year after EVAR. Hundred-seventy-four patients (67 shrinking AAA, 107 stable AAA) who underwent elective, infrarenal EVAR were enrolled between 2011-2018. Long-term survival was significantly better in patients with a shrinking AAA, compared to those with a stable AAA (p = 0.038). Larger preoperative maximum AAA diameter was associated with an increased likelihood of developing AAA shrinkage one-year after EVAR-whereas older age and larger preoperative infrarenal β angle were associated with a reduced likelihood of AAA shrinkage. However, this multivariate logistic regression model was only able to correctly identify 66.7% of patients with AAA shrinkage from the total cohort. This is not sufficient for implementation in clinical care, and therefore future research is recommended to dive deeper into AAA anatomy, and explore potential predictors using artificial intelligence and radiomics.
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Affiliation(s)
- Rianne E. van Rijswijk
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, 7522 NH Enschede, The Netherlands
- Correspondence:
| | - Erik Groot Jebbink
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, 7522 NH Enschede, The Netherlands
| | - Suzanne Holewijn
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
| | - Nicky Stoop
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
| | - Steven M. van Sterkenburg
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
| | - Michel M. P. J. Reijnen
- Department of Vascular Surgery, Rijnstate, 6815 AD Arnhem, The Netherlands; (E.G.J.); (S.H.); (N.S.); (S.M.v.S.); (M.M.P.J.R.)
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, 7522 NH Enschede, The Netherlands
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12
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van Rijswijk RE, Jebbink EG, Zeebregts CJ, Reijnen MMPJ. A systematic review on anatomical predictors of abdominal aortic aneurysm remodeling after endovascular repair. J Vasc Surg 2021; 75:1777-1785. [PMID: 34952192 DOI: 10.1016/j.jvs.2021.11.071] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/23/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Long-term outcomes after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) are inferior to open surgical repair with regard to reinterventions and late mortality. AAA sac remodeling after EVAR has been associated with endoleaks, reinterventions, and mortality. Therefore, predictors of AAA sac remodeling could indirectly give insight into long-term EVAR outcomes. This review aims to provide an overview of the evidence on anatomical predictors of positive and negative AAA sac remodeling after EVAR. METHODS A systematic literature review and analysis were conducted according to the PRISMA and Cochrane guidelines. PubMed and Scopus databases were searched using terms of AAA sac growth, shrinkage, and remodeling. Eligible articles were identified and only papers that included currently used endografts were included. RESULTS Nineteen studies that reported on a total of 27 anatomical parameters of the aortoiliac anatomy were included. Only 4 parameters were investigated by >5 studies, 7 parameters were investigated by 3-5 studies, 6 parameters were investigated by 2 studies, and 10 parameters were investigated by 1 study. For the presence of neck thrombus, 3 out of 4 studies reported similar results indicating that it may predict less AAA sac shrinkage. AAA thrombus, total AAA volume, flow-lumen volume, and the number of hostile neck parameters were only investigated by 2-3 studies, but they seem promising in predicting sac remodeling. For hostile neck anatomy, neck length, infrarenal neck angulation, and patency of the inferior mesenteric artery, no significant association with any category of AAA sac remodeling was found. CONCLUSIONS This review presents neck thrombus, AAA thrombus, number of hostile neck parameters, total AAA volume, and AAA flow-lumen volume as important anatomical features that are likely to play a role in AAA remodeling after endovascular repair that should be further explored using advanced imaging techniques. This review also showed that strong consistent evidence on anatomical predictors of AAA sac remodeling after EVAR is lacking. Therefore, further research with large patient groups on a broad range of predictors of AAA sac change after EVAR is needed to complement the current gap in the evidence.
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Affiliation(s)
- Rianne E van Rijswijk
- Department of Vascular Surgery, Rijnstate, Arnhem, The Netherlands; Multi-Modality Medical Imaging group, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands.
| | - Erik Groot Jebbink
- Department of Vascular Surgery, Rijnstate, Arnhem, The Netherlands; Multi-Modality Medical Imaging group, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Michel M P J Reijnen
- Department of Vascular Surgery, Rijnstate, Arnhem, The Netherlands; Multi-Modality Medical Imaging group, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
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13
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Zoethout AC, Ketting S, Zeebregts CJ, Apostolou D, Mees BME, Berg P, Beyrouti HE, De Vries JPPM, Torella F, Migliari M, Silingardi R, Reijnen MMPJ. An International, Multicenter Retrospective Observational Study to Assess Technical Success and Clinical Outcomes of Patients Treated with an Endovascular Aneurysm Sealing Device for Type III Endoleak. J Endovasc Ther 2021; 29:57-65. [PMID: 34342235 PMCID: PMC8750149 DOI: 10.1177/15266028211031933] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Type III endoleaks post-endovascular aortic aneurysm repair (EVAR) warrant treatment because they increase pressure within the aneurysm sac leading to increased rupture risk. The treatment may be difficult with regular endovascular devices. Endovascular aneurysm sealing (EVAS) might provide a treatment option for type III endoleaks, especially if located near the flow divider. This study aims to analyze clinical outcomes of EVAS for type III endoleaks after EVAR. METHODS This is an international, retrospective, observational cohort study including data from 8 European institutions. RESULTS A total of 20 patients were identified of which 80% had a type IIIb endoleak and the remainder (20%) a type IIIa endoleak. The median time between EVAR and EVAS was 49.5 months (28.5-89). Mean AAA diameter prior to EVAS revision was 76.6±19.9 mm. Technical success was achieved in 95%, 1 patient had technical failure due to a postoperative myocardial infarction resulting in death. Mean follow-up was 22.8±15.2 months. During follow-up 1 patient had a type Ia endoleak, and 1 patient had a new type IIIa endoleak at an untreated location. There were 5 patients with aneurysm growth. Five patients underwent AAA-related reinterventions indications being: growth with type II endoleak (n=3), type Ia endoleak (n=1), and iliac aneurysm (n=1). At 1-year follow-up, the freedom from clinical failure was 77.5%, freedom from all-cause mortality 94.7%, freedom from aneurysm-related mortality 95%, and freedom from aneurysm-related reinterventions 93.8%. CONCLUSION The EVAS relining can be safely performed to treat type III endoleaks with an acceptable technical success rate, a low 30-day mortality rate and no secondary ruptures at short-term follow-up. The relatively low clinical success rates, related to reinterventions and AAA enlargement, highlight the need for prolonged follow-up.
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Affiliation(s)
- Aleksandra C Zoethout
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Vascular Surgery, Rijnstate, Arnhem, The Netherlands
| | - Shirley Ketting
- Department of Vascular Surgery, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Clark J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dimitri Apostolou
- Department of Vascular Surgery, Santa Croce e Carle General Hospital, Cuneo, Italy
| | - Barend M E Mees
- Department of Vascular Surgery, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Patrick Berg
- Department of Vascular & Endovascular Surgery, Katholisches Karl-Leisner-Klinikum, Marienhospital Kevelaer, Kevelaer, Germany
| | - Hazem El Beyrouti
- Department of Cardiothoracic and Vascular surgery, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Jean-Paul P M De Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Francesco Torella
- Liverpool Vascular and Endovascular Service, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | - Mattia Migliari
- Department of Vascular Surgery, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Michel M P J Reijnen
- Department of Vascular Surgery, Rijnstate, Arnhem, The Netherlands.,Multimodality-Medical Imaging Group, University of Twente, Enschede, The Netherlands
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14
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Rossi GP, Lenzini L, Caroccia B, Rossitto G, Seccia TM. Angiotensin peptides in the regulation of adrenal cortical function. EXPLORATION OF MEDICINE 2021. [DOI: 10.37349/emed.2021.00047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The adrenal cortex plays a key role in the regulation of metabolism, salt and water homeostasis and sex differentiation by synthesizing glucocorticoid, mineralocorticoid and androgen hormones. Evidence exists that angiotensin II regulates adrenocortical function and it has been contended that angiotensin peptides of the non-canonical branch of the renin angiotensin system (RAS) might also modulate steroidogenesis in adrenals. Thus, the aim of this review is to examine the role of the RAS, and particularly of the angiotensin peptides and their receptors, in the regulation of adrenocortical hormones with particular focus on aldosterone production.
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Affiliation(s)
- Gian Paolo Rossi
- Emergency Medicine Unit and European Society of Hypertension Specialized Center of Excellence for Hypertension, Department of Medicine-DIMED, University of Padua, Italy
| | - Livia Lenzini
- Emergency Medicine Unit and European Society of Hypertension Specialized Center of Excellence for Hypertension, Department of Medicine-DIMED, University of Padua, Italy
| | - Brasilina Caroccia
- Emergency Medicine Unit and European Society of Hypertension Specialized Center of Excellence for Hypertension, Department of Medicine-DIMED, University of Padua, Italy
| | - Giacomo Rossitto
- Emergency Medicine Unit and European Society of Hypertension Specialized Center of Excellence for Hypertension, Department of Medicine-DIMED, University of Padua, Italy
| | - Teresa Maria Seccia
- Emergency Medicine Unit and European Society of Hypertension Specialized Center of Excellence for Hypertension, Department of Medicine-DIMED, University of Padua, Italy
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15
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Kawada H, Goshima S, Sakurai K, Noda Y, Kajita K, Tanahashi Y, Kawai N, Ishida N, Shimabukuro K, Doi K, Matsuo M. Utility of Noncontrast Magnetic Resonance Angiography for Aneurysm Follow-Up and Detection of Endoleaks after Endovascular Aortic Repair. Korean J Radiol 2020; 22:513-524. [PMID: 33543842 PMCID: PMC8005350 DOI: 10.3348/kjr.2020.0001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 06/02/2020] [Accepted: 06/22/2020] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Hiroshi Kawada
- Department of Radiology, Gifu University Hospital, Gifu, Japan
| | - Satoshi Goshima
- Department of Radiology, Gifu University Hospital, Gifu, Japan.,Department of Diagnostic Radiology and Nuclear Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan.
| | - Kota Sakurai
- Department of Radiology, Chuno Kosei Hospital, Seki, Japan
| | - Yoshifumi Noda
- Department of Radiology, Gifu University Hospital, Gifu, Japan
| | - Kimihiro Kajita
- Department of Radiology Services, Gifu University Hospital, Gifu, Japan
| | | | - Nobuyuki Kawai
- Department of Radiology, Gifu University Hospital, Gifu, Japan
| | - Narihiro Ishida
- Department of General and Cardiothoracic Surgery, Gifu University Hospital, Gifu, Japan
| | - Katsuya Shimabukuro
- Department of General and Cardiothoracic Surgery, Gifu University Hospital, Gifu, Japan
| | - Kiyoshi Doi
- Department of General and Cardiothoracic Surgery, Gifu University Hospital, Gifu, Japan
| | - Masayuki Matsuo
- Department of Radiology, Gifu University Hospital, Gifu, Japan
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16
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Zoethout AC, Sheriff A, Zeebregts CJ, Reijnen MMPJ, Hill A, Holden A. Migration After Endovasclar Aneurysm Sealing in Conjunction With Chimney Grafts. J Endovasc Ther 2020; 28:165-172. [PMID: 32909531 PMCID: PMC7816544 DOI: 10.1177/1526602820957279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Purpose To assess the incidence of migration after endovascular aneurysm sealing (EVAS) in conjunction with chimney grafts (chEVAS) for repair of abdominal aortic aneurysms (AAAs). Materials and Methods A retrospective, observational cohort study was conducted of 31 patients (mean age 75.7 years; 27 men) treated for juxtarenal AAA between April 2013 and December 2018 at single centers in New Zealand and the Netherlands. The majority of patients received >1 chimney graft (13 single, 13 double, and 5 triple) during chEVAS. Six patients had only the first postoperative scan, so the migration analysis was based on 25 patients. Results Median seal length assessed on the first postoperative computed tomography scan was 36.5 mm. The assisted technical success rate was 93.5% with 2 technical failures. Median time to final imaging follow-up was 17 months in 25 patients. At the latest follow-up, there were no cases of caudal migration >10 mm. Freedom from caudal movement of 5 to 9 mm was estimated as 86.1% at 1 year and 73.9% at 2 years; freedom from clinically relevant migration (movement requiring reintervention) was 100% at both time intervals. However, at 3 years there were 2 cases of caudal movement of 5 to 9 mm and a type Ia endoleak warranting reintervention. No correlation between migration and aneurysm growth (p=0.851), endoleak (p=0.562), or the number of chimney grafts (p=0.728) was found. During follow-up, 2 patients (7%) had aneurysm rupture and 10 (33%) had reinterventions. Eight patients (27%) died; 2 were aneurysm-related (7%) and due to the consequences of a reintervention. Conclusion In the 2 years following chEVAS, there was no caudal migration >10 mm, but nearly a quarter of patients had caudal movement of 5 to 9 mm. A trend was observed toward ongoing migration that required intervention at 3-year follow-up. chEVAS is technically challenging and should be considered only for patients with no viable alternative treatment option.
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Affiliation(s)
- Aleksandra C Zoethout
- Department of Interventional Radiology and Vascular Surgery, Auckland City Hospital, Auckland, New Zealand.,Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, the Netherlands.,Department of Vascular Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Arshad Sheriff
- Department of Interventional Radiology and Vascular Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Clark J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Michel M P J Reijnen
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, the Netherlands.,MultiModality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Andrew Hill
- Department of Interventional Radiology and Vascular Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Andrew Holden
- Department of Interventional Radiology and Vascular Surgery, Auckland City Hospital, Auckland, New Zealand
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17
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Farzaneh C, Fujitani R, De Virgilio C, Grigorian A, Duong W, Kabutey NK, Lekawa M, Nahmias J. Analysis of Endovascular Aneurysm Repair for Small Abdominal Aortic Aneurysms in Males. J Surg Res 2020; 256:163-170. [PMID: 32707399 DOI: 10.1016/j.jss.2020.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/09/2020] [Accepted: 06/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Current guidelines recommend repair of abdominal aortic aneurysms (AAAs) when ≥5.5 cm. This study sought to evaluate the incidence of male patients undergoing endovascular aneurysm repair (EVAR) for AAAs of various diameters (small <4 cm; intermediate 4-5.4 cm; standard ≥5.5 cm). We analyzed predictors of mortality, hypothesizing that smaller AAAs (<5.5 cm) have no differences in associated risk of mortality compared to standard AAAs (≥5.5 cm). METHODS The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for male patients undergoing elective EVAR. Patients were stratified by aneurysm diameter. A multivariable logistic regression analysis for clinical outcomes, adjusting for age, clinical characteristics, and comorbidities, was performed. RESULTS A total of 8037 male patients underwent EVAR with 3926 (48.9%) performed for AAAs <5.5 cm. There was no difference in mortality, readmission, major complications, myocardial infarction, stroke, or ischemic complications among the 3 groups (P > 0.05). In AAAs <5.5 cm, predictors of mortality included prior abdominal surgery (odds ratio [OR], 5.77; confidence interval [CI], 1.38-24.13; P = 0.016), weight loss (OR, 43.4; CI, 3.78-498.7; P = 0.002), disseminated cancer (OR, 17.9; CI, 1.30-245.97; P = 0.031), and diabetes (OR, 6.09; CI, 1.52-24.36; P = 0.011). CONCLUSIONS Nearly 50% of male patients undergoing elective EVAR were treated for AAAs <5.5 cm. There was no difference in associated risk of mortality for smaller AAAs compared to standard AAAs. The strongest predictors of mortality for patients with smaller AAAs were prior abdominal surgery, weight loss, disseminated cancer, and diabetes.
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Affiliation(s)
- Cyrus Farzaneh
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California
| | - Roy Fujitani
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine, Orange, California
| | - Christian De Virgilio
- Department of Surgery, University of California, Los Angeles - Harbor, Torrance, California
| | - Areg Grigorian
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California
| | - William Duong
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California
| | - Nii-Kabu Kabutey
- Division of Vascular Surgery, Department of Surgery, University of California, Irvine, Orange, California
| | - Michael Lekawa
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California
| | - Jeffry Nahmias
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California.
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18
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Abstract
There are several vascular ultrasound technologies that are useful in challenging diagnostic situations. New vascular ultrasound applications include directional power Doppler ultrasound, contrast-enhanced ultrasound, B-flow imaging, microvascular imaging, 3-dimensional vascular ultrasound, intravascular ultrasound, photoacoustic imaging, and vascular elastography. All these techniques are complementary to Doppler ultrasound and provide greater ability to visualize small vessels, have higher sensitivity to detect slow flow, and better assess vascular wall and lumen while overcoming limitations color Doppler. The ultimate goal of these technologies is to make ultrasound competitive with computed tomography and magnetic resonance imaging for vascular imaging.
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Affiliation(s)
- Lori Mankowski Gettle
- University of Wisconsin - Madison, 600 Highland Avenue, E3/380, Madison, WI 53792, USA.
| | - Margarita V Revzin
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Yale New Haven Hospital, 330 Cedar Street, TE 2-214, New Haven, CT 06520, USA. https://twitter.com/MargaritaRevzin
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19
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Tanaka A, Charlton-Ouw KM. Open thoracoabdominal aortic aneurysm repair in the endovascular era. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.19.01428-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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20
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Canteras M, Baptista‐Silva JCC, do Carmo Novaes F, Cacione DG. Transverse versus vertical groin incision for femoral artery approach. Cochrane Database Syst Rev 2020; 4:CD013153. [PMID: 32319682 PMCID: PMC7175778 DOI: 10.1002/14651858.cd013153.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Access to the femoral vessels is necessary for a wide range of vascular procedures, including treatment of thromboembolic disease, arterial grafts (i.e. bifemoral aortic bypass or infrainguinal bypass), endovascular repair of abdominal aortic aneurysm (EVAR), thoracic endovascular aneurysm repair (TEVAR) and transcatheter aortic valve implantation (TAVI). The surgical technique used to access the femoral artery may be a factor in the occurrence of postoperative complications; this will be the focus of our review. We will compare the transverse surgical technique-a cut made parallel to the groin crease-versus the vertical groin incision surgical technique-classic technique: a surgical cut made across the groin crease-to access the femoral artery, in an attempt to determine which technique has the lower rate of complications, is safer and is more effective. OBJECTIVES To evaluate the efficacy and safety of transverse groin incision compared with vertical groin incision for accessing the femoral artery in endovascular surgical procedures and open surgery. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases, and the World Health Organization (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to 17 February 2020. The review authors searched the IBECS database to 26 March 2020 and reference lists of relevant studies/papers. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-randomized trials (qRCTs) that compare transverse and vertical groin incision, during either endovascular or open surgery procedures. DATA COLLECTION AND ANALYSIS Two review authors (MVCRC, FCN) independently selected the studies, assessed risk of bias, extracted data, performed data analysis and graded the certainty of evidence according to GRADE. MAIN RESULTS We included one RCT and one qRCT in this review. These two studies had a combined total of 237 participants (283 groins). Infection of the surgical wound was the only outcome that was similar in both studies, and that could therefore be submitted to a combined analysis. Meta-analysis of the two studies showed low-certainty evidence that transverse groin incision resulted in a lower risk of surgical wound infection in the 10- to 28-day period following surgery (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.08 to 0.76; 2 studies; 283 groin incisions). There was low heterogeneity between the studies. We downgraded the certainty of the evidence for surgical wound infection by one level due to serious limitations in the design (there was a high risk of bias in critical domains). The confidence interval for surgical wound infection is relatively wide, further indicating that the certainty of the effect estimate is low. This is likely due to the small number of studies and participants. We observed no evidence of a difference between the two surgical techniques for the other evaluated primary outcome 'lymphatic complications': lymphocele (RR 0.46, 95% CI 0.20 to 1.02; 1 study; 116 groins); and lymphorrhea (RR 2.77, 95% CI 0.92 to 8.34; 1 study; 116 groins). We downgraded the certainty of evidence for lymphatic complications by one level due to serious limitations in the design (there was a high risk of bias in critical domains); and by two further levels because of imprecision (small number of participants and only one study included). High-quality studies are needed to enable a comparison of the two surgical techniques with respect to other outcomes, such as infection of the vascular graft (endoprosthesis/prosthesis), prolonged hospitalization, reoperative surgery, death, neurological deficit (e.g. paresthesia), amputation, graft patency, and postoperative pain. AUTHORS' CONCLUSIONS In this systematic review, we found low-certainty evidence that performing transverse groin incision to access the femoral artery resulted in fewer surgical wound infections compared with performing vertical groin incision. We observed no evidence of a difference between the two surgical techniques for the other evaluated outcomes (lymphocele and lymphorrhea). Other outcomes were not evaluated in these studies. Limitations of this systematic review are, however, the small sample size, short clinical follow-up period and high risk of bias in critical domains. For this reason, the applicability of the results is limited.
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Affiliation(s)
- Marcus Canteras
- UNIFESP – Escola Paulista de MedicinaDepartment of SurgeryRua Borges Lagoa, cj 564, CJ 124Vila ClementinoSão PauloSão PauloBrazil04038000
| | - Jose CC Baptista‐Silva
- Universidade Federal de São PauloEvidence Based Medicine, Cochrane BrazilRua Borges Lagoa, 564, cj 124São PauloSão PauloBrazil04038‐000
| | - Frederico do Carmo Novaes
- UNIFESP – Escola Paulista de MedicinaDepartment of SurgeryRua Borges Lagoa, cj 564, CJ 124Vila ClementinoSão PauloSão PauloBrazil04038000
| | - Daniel G Cacione
- UNIFESP – Escola Paulista de MedicinaDivision of Vascular and Endovascular Surgery, Department of SurgeryRua Borges Lagoa, 564 cj 124Vila ClementinoSão PauloBrazil04038000
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D'Oria M, Mastrorilli D, Ziani B. Natural History, Diagnosis, and Management of Type II Endoleaks after Endovascular Aortic Repair: Review and Update. Ann Vasc Surg 2020; 62:420-431. [PMID: 31376537 DOI: 10.1016/j.avsg.2019.04.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/02/2019] [Accepted: 04/28/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Mayo Clinic Gonda Vascular Center, Rochester, MN; Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy.
| | - Davide Mastrorilli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Barbara Ziani
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
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Conway AM, Qato K, Nguyen Tran NT, Stoffels GJ, Giangola G, Carroccio A. Cross-clamp location affects short-term survival in patients undergoing open abdominal aortic aneurysm repair. J Vasc Surg 2019; 72:144-153. [PMID: 31831312 DOI: 10.1016/j.jvs.2019.09.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/11/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Open abdominal aortic aneurysm (oAAA) repair in the era of advanced endovascular aortic techniques is used in challenging anatomy. The impact of the location of the proximal aortic cross-clamp (suprarenal [SR] vs infrarenal [IR]) on outcomes remains to be determined. The aim of this study was to analyze the effect of proximal aortic cross-clamp location on short-term and overall survival after oAAA repair in a contemporary series. METHODS A retrospective cohort study was performed comparing the outcomes of patients undergoing oAAA repair with SR and IR aortic cross-clamping using the Vascular Quality Initiative registry from January 2003 to September 2018. Our primary end point was short-term mortality. RESULTS There were 7601 patients who underwent oAAA repair. Their mean age was 69.3 ± 8.5 years and 5555 patients (73.1%) were male. The aortic cross-clamp location was IR in 4044 patients (53.2%). The SR group had increased maximum AAA diameter (58 mm vs 56 mm; P < .0001), hypertension (85.5% vs 82.0%; P < .0001), preoperative creatinine (1.11 vs 1.08; P = .001), and were more likely to be in American Society of Anesthesiologists class IV (37.4% vs 30.6%; P < .0001). Postoperative renal failure occurred significantly more often in the SR group (24.4 vs 11.4%; P < .0001). Short-term mortality was 2.7% in the IR group and 4.7% in the SR group (P < .0001). Kaplan-Meier survival estimates were 93.7% and 83.8% in the IR group and 90.9% and 81.2% in the SR group at 1 and 5 years, respectively (P = .007). Multivariable analysis demonstrated that SR cross-clamping was significantly associated with short-term mortality (hazard ratio, 1.38; 95% confidence interval, 1.07-1.78; P = .01); however, it did not affect overall survival (hazard ratio, 1.13; 95% confidence interval, 1.00-1.28; P = .06). CONCLUSIONS A SR cross-clamp location is associated with an increased short-term mortality in patients undergoing oAAA repair. Overall survival is not affected by a SR cross-clamp location.
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Affiliation(s)
- Allan M Conway
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY.
| | - Khalil Qato
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Nhan T Nguyen Tran
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | | | - Gary Giangola
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Alfio Carroccio
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
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Zoethout AC, Zerwes S, Zeebregts CJ, Heyligers JM, De Vries JPJ, Oberhuber A, Karl T, Berg P, Stenson K, Loftus I, Torella F, Szopiński P, Zimmermann E, Holden A, Hyhlik-Duerr A, Reijnen MM. Preliminary outcome of Nellix-in-Nellix extensions in patients treated with failed endovascular aneurysm sealing. J Vasc Surg 2019; 70:1099-1106. [DOI: 10.1016/j.jvs.2019.01.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 01/01/2019] [Indexed: 11/25/2022]
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Yalcin M, Tiryakioglu O. Single-center Study Comparing Short and Mid-Term Results of EVAR in Old and Young Populations. Braz J Cardiovasc Surg 2019; 34:279-284. [PMID: 31310465 PMCID: PMC6629225 DOI: 10.21470/1678-9741-2018-0021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective The purpose of this study was to compare the operative mortality rate and
outcomes of endovascular aneurysm repair (EVAR) between young and geriatric
people in a single center. Methods Eighty-five patients with abdominal aortic aneurysms who underwent EVAR
between January 2012 and September 2016 were included. Outcomes were
compared between two groups: the young (aged < 65 years) and the
geriatric (aged ≥ 65 years). The primary study outcome was technical
success; the secondary endpoints were mortality and secondary interventions.
The mean follow-up time was 36 months (3-60 months). Results The study included 72 males and 13 females with a mean age of
71.08±8.6 years (range 49-85 years). Of the 85 patients analyzed, 18
(21.2%) were under 65 years old and 67 patients (78.8%) were over 65 years
old. There was no statistically significant correlation between chronic
disease and age. We found no statistically significant difference between
aneurysm diameter, neck angle, neck length, or right and left iliac angles.
The secondary intervention rate was 7% (six patients). The conversion to
open surgery was necessary for only one patient and only three deaths were
reported (3.5%). There was no statistically significant difference in the
mortality and reintervention rates between the age groups. The three deaths
occurred only in the geriatric group and two died secondary to rupture.
Kidney failure was observed in three patients in the geriatric group
(4.5%). Conclusion Our single-center experience shows that EVAR can be used safely in both young
and geriatric patients.
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Affiliation(s)
- Mihriban Yalcin
- Ordu State Hospital Department of Cardiovascular Surgery Ordu Turkey Department of Cardiovascular Surgery, Ordu State Hospital, Ordu, Turkey
| | - Osman Tiryakioglu
- Bahcesehir University Medical Faculty Department of Cardiovascular Surgery Bursa Turkey Department of Cardiovascular Surgery, Medical Faculty, Bahcesehir University, Bursa, Turkey
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Dua A, Rothenberg KA, Wohlaer M, Rossi PJ, Lewis BD, Brown KR, Seabrook GR, Lee CJ. Unplanned 30-day readmissions after endovascular aneurysm repair: An analysis using the Nationwide Readmissions Database. J Vasc Surg 2019; 70:1603-1611. [PMID: 31147138 DOI: 10.1016/j.jvs.2019.02.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 02/12/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) is the preferred method for addressing abdominal aortic aneurysms (AAAs), with proven reduction in perioperative morbidity and mortality. There are, however limited data examining the readmissions after EVAR that are associated with increased patient morbidity and cost. As EVAR use continues its dominance in the management of AAAs, it becomes imperative to identify and mitigate risk factors associated with unplanned hospital readmissions. METHODS The Nationwide Readmissions Database (NRD) was queried for all 30-day readmissions after an index EVAR procedure from 2012 to 2014. Preoperative patient demographics, hospital characteristics, readmission diagnosis, and costs were compared between those who were and were not readmitted within 30 days of the index operation. Multivariable logistic regression was used to identify potential risk factors associated with unplanned readmissions within 30 days. RESULTS We identified 120,646 patients who underwent an EVAR from 2012 to 2014 in the United States. The overall unplanned readmission rate during this period was 11.6% (n = 14,073) within 30 days of the index EVAR procedure. The readmission rate was the highest in 2012, with a rate of 12.3% (P = .02). Multivariate regression analysis showed that EVAR readmissions were significantly higher in patients who were of younger age (18 to 49 years) compared with other age groups (odds ratio [OR], 1.9-2.17; P < .001), female sex (OR, 1.367; P < .001), had Medicare (OR, 1.39) or Medicaid (OR, 1.25) insurance, or a combination of these. Underlying patient comorbidities significantly associated with readmissions included congestive heart failure (OR, 2.4), peripheral vascular disease (OR, 1.1), chronic pulmonary disease (OR, 1.2), cancer with no metastasis (OR, 1.5), metastatic cancer (OR, 2.2), renal failure (OR, 1.8), and diabetes (OR, 1.5). CONCLUSIONS The trend in 30-day readmission rates after EVAR has decreased slightly since 2012, but overall rates are at 11.6%, which is not insubstantial. Patient factors strongly associated with hospital readmission were younger age and patient comorbidities, including congestive heart failure, concurrent cancer diagnosis, renal failure, and diabetes.
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Affiliation(s)
- Anahita Dua
- Division of Vascular Surgery, Stanford Hospitals and Clinics, Palo Alto, Calif
| | - Kara A Rothenberg
- Division of Vascular Surgery, Stanford Hospitals and Clinics, Palo Alto, Calif
| | - Max Wohlaer
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisc
| | - Peter J Rossi
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisc
| | - Brian D Lewis
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisc
| | - Kellie R Brown
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisc
| | - Gary R Seabrook
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisc
| | - Cheong J Lee
- Division of Vascular Surgery, NorthShore University HealthSystem, Highland Park, Ill.
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McFarland G, Tran K, Virgin-Downey W, Sgroi MD, Chandra V, Mell MW, Harris EJ, Dalman RL, Lee JT. Infrarenal endovascular aneurysm repair with large device (34- to 36-mm) diameters is associated with higher risk of proximal fixation failure. J Vasc Surg 2019; 69:385-393. [DOI: 10.1016/j.jvs.2018.02.054] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/07/2018] [Indexed: 11/25/2022]
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Canteras M, Baptista-Silva JCC, Cacione DG. Transverse versus longitudinal inguinotomy for femoral artery approach. Hippokratia 2018. [DOI: 10.1002/14651858.cd013153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Marcus Canteras
- UNIFESP - Escola Paulista de Medicina; Department of Surgery; Rua Borges Lagoa, cj 564, CJ 124 Vila Clementino São Paulo São Paulo Brazil 04038000
| | - Jose CC Baptista-Silva
- Universidade Federal de São Paulo; Evidence Based Medicine, Cochrane Brazil; Rua Borges Lagoa, 564, cj 124 São Paulo São Paulo Brazil 04038-000
| | - Daniel G Cacione
- UNIFESP - Escola Paulista de Medicina; Division of Vascular and Endovascular Surgery, Department of Surgery; Rua Borges Lagoa, 564 cj 124 Vila Clementino São Paulo Brazil 04038000
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Wang T, Zhao J, Yuan D, Ma Y, Huang B, Yang Y, Zeng G. Comparative effectiveness of open surgery versus endovascular repair for hemodynamically stable and unstable ruptured abdominal aortic aneurysm. Medicine (Baltimore) 2018; 97:e11313. [PMID: 29979402 PMCID: PMC6076075 DOI: 10.1097/md.0000000000011313] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Several observational studies and randomized trials have compared open surgery (OS) and endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA). However, none of these studies addressed optimal management of hemodynamically (hd) unstable patients. Our objective was to compare perioperative outcomes in patients undergoing OS vs EVAR for hd-stable and hd-unstable rAAAs.This retrospective study was conducted in West China Hospital from January 2005 to December 2015. Unstable patients were defined as those who have at least 1 of the following: preoperative shock, preoperative transfusion >4 units, preoperative intubation, cardiac arrest, or unconsciousness. Univariable and multivariable logistic regression analyses were performed.Of the 102 patients, 70.6% underwent OS and 29.4% EVAR. About 46.1% were unstable, and for these patients, OS was performed in 70.2% and EVAR in 29.8%. The 30-day mortality was 23.6% (OS, 25.6%; EVAR, 18.8%; P = .585) for hd-stable patients and was 42.6% (OS, 45.5%; EVAR, 35.7%; P = .537) for hd-unstable patients. Patients with OS had longer operative time and more transfusion. Amongst hd-stable patients, OS subgroup had a higher rate of pneumonia (33.3% vs 6.3%, P = .045), longer intensive care unit (ICU) stay (43.2 vs 15.2 hours, P = .02), and length of stay (11.6 vs 8.6 days, P = .041). Among hd-unstable patients, OS subgroup had a longer ICU stay (134.3 vs 63.8 hours, P = .047). Hospitalization costs of OS group were significantly lower than those of EVAR group, regardless of hemodynamic stability.Approximately one-third of patients with rAAA were treated by EVAR at our institution. EVAR may be the preferred approach for anatomically suitable rAAAs. However, patients treated by EVAR had a similar mortality compared with those treated by OS. In addition, OS is not an independent factor for a higher 30-day mortality, and the costs of OS were much cheaper than those of EVAR. Therefore, OS is difficult to replace, especially in developing countries.
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Outcomes over Time in Patients with Hostile Neck Anatomy Undergoing Endovascular Repair of Abdominal Aortic Aneurysm. J Vasc Interv Radiol 2018; 29:1011-1016. [DOI: 10.1016/j.jvir.2018.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 03/01/2018] [Accepted: 03/02/2018] [Indexed: 11/23/2022] Open
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Adkar SS, Turner MC, Leraas HJ, Gilmore BF, Nag U, Turley RS, Shortell CK, Mureebe L. Low mortality rates after endovascular aortic repair expand use to high-risk patients. J Vasc Surg 2018; 67:424-432.e1. [PMID: 28951155 PMCID: PMC7243615 DOI: 10.1016/j.jvs.2017.06.107] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/22/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The 2010 endovascular aneurysm repair (EVAR) trial 2 (EVAR 2) reported that patients with comorbidity profiles rendering them unfit for open aneurysm repair who underwent EVAR did not experience a survival advantage compared with those who did not undergo intervention. These patients experienced a 30-day mortality of 7.3%, whereas reports from similar cohorts reported far lower mortality rates. The primary objective of our study was to compare the incidence of 30-day mortality in low- and high-risk patients undergoing EVAR in a contemporary data set, using patient risk stratification criteria from EVAR 2. Secondarily, we sought to identify risk factors associated with a disproportionate contribution to 30-day mortality risk. METHODS Data were obtained from the 2005 to 2013 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data Files (N = 24,813). Patients were included in the high-risk cohort with the presence of renal, respiratory, or cardiac preoperative criteria alone or in combination. Renal impairment criteria were defined as dialysis and creatinine concentration >2.26 mg/dL. Respiratory impairment criteria included history of chronic obstructive pulmonary disease and preoperative ventilator support. Cardiac impairment criteria included history of myocardial infarction, congestive heart failure, angina, and prior coronary intervention. Patient and procedural characteristics and 30-day postoperative outcomes were compared using Pearson χ2 tests for categorical variables and Wilcoxon rank sum tests for continuous variables. RESULTS Among 24,813 patients undergoing EVAR, 12,043 (48%) patients were characterized as high risk (at least one impairment criterion); 12,770 (52%) patients were stratified as low risk. The 30-day mortality rate was 1.9% in the high-risk cohort compared with the 7.3% reported by EVAR 2, and it was higher in the high-risk cohort compared with the low-risk cohort (1.9% vs 0.9%; P < .001). Whereas the presence of each comorbidity increased the odds of 30-day mortality (respiratory odds ratio [OR], 1.62; 95% confidence interval [CI], 1.16-2.26; P = .005; cardiac OR, 1.55; 95% CI, 1.14-2.10; P = .005), the presence of renal criteria disproportionately increased the odds of mortality threefold (OR, 3.42; 95% CI, 2.31-5.09; P < .001). CONCLUSIONS Contemporary 30-day mortality after EVAR in high-risk patients is substantially lower than that reported in the EVAR 2 trial. Whereas low- and high-risk stratification by current comorbidity criteria is appropriate, attention needs to be paid to disproportionate risk contribution from renal disease to mortality compared with cardiac and pulmonary comorbidities. Given the lower mortality risk than previously described, patients stratified as high risk should be thoughtfully considered for definitive EVAR.
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Affiliation(s)
- Shaunak S Adkar
- Duke University School of Medicine, Duke University Medical Center, Durham, NC.
| | - Megan C Turner
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Harold J Leraas
- Duke University School of Medicine, Duke University Medical Center, Durham, NC
| | - Brian F Gilmore
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Uttara Nag
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ryan S Turley
- Department of Surgery, Duke University Medical Center, Durham, NC; Cardiothoracic Vascular Surgeons, Austin, Tex
| | | | - Leila Mureebe
- Department of Surgery, Duke University Medical Center, Durham, NC
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Machado R, Teixeira G, Oliveira P, Loureiro L, Pereira C, Almeida R. Is Age a Determinant Factor in EVAR as a Predictor of Outcomes or in the Selection Procedure? Our Experience. Braz J Cardiovasc Surg 2017; 31:132-9. [PMID: 27556312 PMCID: PMC5062736 DOI: 10.5935/1678-9741.20160037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 04/25/2016] [Indexed: 11/26/2022] Open
Abstract
Introduction Endovascular aneurysm repair (EVAR) is the therapy of choice in high risk
patients with abdominal aortic aneurysm. The good results described are
leading to the broadening of clinical indications to younger patients.
However, reintervention rates seem higher and even with successful treatment
sometimes there is growth of the aneurysm sac and rupture, meaning a failure
of the therapeutic goal. This study proposes to analyse the impact of age in
patients' selection and post-EVAR results. Methods The clinical records of consecutive patients undergoing endovascular aneurysm
repair, between 2001 and 2013, were retrospectively reviewed. Patients were
divided according to age groups (<70, 70-80 and >80 years). Gender,
body mass index, aneurysm anatomic features, neck characteristics, iliac
morphology, surgical indication, endograft type, anesthesic risk
classification, length of stay, reinterventions and mortality were analysed
and compared. Results The study included 171 patients, 161 (94.1%) men, and mean age
74.1±8.9 years. The age group under 70 had 32% of the patients. Only
three characteristics were found different among age groups: 1) body mass
index was higher in younger patients, with a considerable trend toward
significance (P=0.06); 2) surgical indication, in the younger group,
surgeon's and the patient's option were more proeminent
(P<0.05); 3) erectile dysfunction was higher in elderly
group (P<0.05). No other clinical and anatomical
characteristics or final outcomes were found statisticaly different among
age groups. Conclusion The absence of statistically differences in mortality and reinterventions
among age groups suggests that age by itself is not a relevant factor in
endovascular aneurysm repair. Indeed, the three characteristics different in
younger (obesity, sexual function and patient's choice) favor endovascular
aneurysm repair.
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Affiliation(s)
- Rui Machado
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Gabriela Teixeira
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Pedro Oliveira
- Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | - Luís Loureiro
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Carlos Pereira
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Rui Almeida
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
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Kalra K, Arya S. A comparative review of open and endovascular abdominal aortic aneurysm repairs in the national operative quality improvement database. Surgery 2017; 162:979-988. [DOI: 10.1016/j.surg.2017.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/11/2017] [Indexed: 01/25/2023]
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Aiello F, Durgin J, Daniel V, Messina L, Doucet D, Simons J, Jenkins J, Schanzer A. Surgeon leadership in the coding, billing, and contractual negotiations for fenestrated endovascular aortic aneurysm repair increases medical center contribution margin and physician reimbursement. J Vasc Surg 2017; 66:997-1006. [DOI: 10.1016/j.jvs.2017.01.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/24/2017] [Indexed: 11/16/2022]
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Abstract
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.
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Affiliation(s)
- Karol Meyermann
- Division of Vascular Surgery, Department of Surgery, Cooper University Hospital, Suite 411, 3 Cooper Plaza, Camden, NJ 08103, USA
| | - Francis J Caputo
- Division of Vascular Surgery, Department of Surgery, Cooper University Hospital, Suite 411, 3 Cooper Plaza, Camden, NJ 08103, USA.
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Schaeffer JS, Shakhnovich I, Sieck KN, Kallies KJ, Davis CA, Cogbill TH. Duplex Ultrasound Surveillance After Uncomplicated Endovascular Abdominal Aortic Aneurysm Repair. Vasc Endovascular Surg 2017; 51:295-300. [PMID: 28535732 DOI: 10.1177/1538574417708131] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Health-care costs and risks of radiation and intravenous contrast exposure challenge computed tomography angiography (CTA) as the standard surveillance method after endovascular abdominal aortic aneurysm repair (EVAR). We reviewed our experience using Duplex ultrasound scan (DUS) as an initial and subsequent surveillance technique after uncomplicated EVAR. METHODS The medical records of patients who underwent EVAR from 2004 to 2014 with at least 1 postoperative imaging study were retrospectively reviewed. Duplex ultrasound scan was the primary modality, with CTA reserved for patients with suspicious findings. RESULTS Mean follow-up was 3.2 years for 266 patients. Fifty-seven endoleaks (7 type I, 50 type II) were detected in 51 patients (19%). Nineteen (33%) endoleaks were identified and monitored by DUS alone. Nine (16%) endoleaks were identified on CTA without prior DUS. Twenty-two (39%) endoleaks were identified on DUS and confirmed by CTA; 6 of these patients had a secondary intervention. When compared to subsequent CTA, there were 7 discordant results: 4 false-negative and 3 false-positive endoleaks on DUS. Two of these patients with discordant results required intervention. Follow-up CTA was not obtained for the other 2 patients due to severe comorbidities including renal disease. One of these patients eventually developed abdominal aortic aneurysm rupture and death. Among 88 patients with both DUS and CTA, positive predictive value and negative predictive value for DUS were 0.88 and 0.94, respectively. Sac size on DUS compared to CTA resulted in an interclass correlation coefficient of r = .84. CONCLUSIONS In our experience, DUS was safe and effective for initial and follow-up surveillance after uncomplicated EVAR.
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Affiliation(s)
- Jacob S Schaeffer
- 1 General Surgery Residency, Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Irina Shakhnovich
- 2 Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI, USA
| | - Kyle N Sieck
- 3 Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Kara J Kallies
- 3 Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Clark A Davis
- 2 Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI, USA
| | - Thomas H Cogbill
- 2 Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI, USA
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Kontopodis N, Papadopoulos G, Galanakis N, Tsetis D, Ioannou CV. Improvement of patient eligibility with the use of new generation endografts for the treatment of abdominal aortic aneurysms. A comparison study among currently used endografts and literature review. Expert Rev Med Devices 2017; 14:245-250. [DOI: 10.1080/17434440.2017.1281738] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University of Crete Medical School, Heraklion, Greece
| | - George Papadopoulos
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University of Crete Medical School, Heraklion, Greece
| | - Nikolaos Galanakis
- Interventional Radiology Unit, Radiology Department, University of Crete Medical School, Heraklion, Greece
| | - Dimitrios Tsetis
- Interventional Radiology Unit, Radiology Department, University of Crete Medical School, Heraklion, Greece
| | - Christos V. Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University of Crete Medical School, Heraklion, Greece
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Ioannou CV, Kontopodis N, Peteinarakis I, Tsetis D. Noninvasive Estimation of Aneurysm Sac Pressurization Following Endovascular Aneurysm Repair Using M-Mode Ultrasonography to Evaluate Significance of Endoleaks: A Feasibility Study. J Endovasc Ther 2016; 23:606-13. [PMID: 27099286 DOI: 10.1177/1526602816645524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To establish the feasibility of indirectly estimating aneurysm sac pressurization from recordings of aortic pulsatile wall motion (PWM) using M-mode ultrasonography before and after endovascular aneurysm repair (EVAR). METHODS Twenty consecutive patients (mean age 72 years; 19 men) scheduled for EVAR in a single institution underwent M-mode ultrasonography 1 day before EVAR to record PWM of the abdominal aortic aneurysm wall during the cardiac cycle, along with simultaneous blood pressure measurements. The recording was repeated the first postoperative day. Pressure-strain elastic modulus (Ep) was calculated from the preoperative displacement and pressure data. This value and the postoperative PWM were used to inverse estimate pulse pressure in the abdominal aortic aneurysm sac post EVAR. Immediate pressure reduction post EVAR was compared between groups of endoleak vs no endoleak and expansion vs no expansion during 6-month follow-up. RESULTS Intraobserver variability of the method presented a mean value of 0.04 mm with a 1.2-mm coefficient of variation (95% limits of agreement -1.16 to 1.24 mm). PWM was significantly reduced postoperatively (1.2 vs 0.3 mm, p<0.001) as was pulse pressure exerted on the aneurysm sac (67 vs 16 mm Hg, p<0.001). The pressure reduction was similar between the endoleak vs no endoleak groups (79% vs 75%, p=0.65), but it was significantly greater in the no expansion group (79.5%) vs the group with aneurysm expansion (50%, p=0.008). CONCLUSION M-mode ultrasonography may provide a useful adjunct during EVAR surveillance to noninvasively estimate sac pressurization and identify aneurysms at risk of enlargement.
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Affiliation(s)
- Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University of Crete Medical School, Heraklion, Crete, Greece
| | - Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University of Crete Medical School, Heraklion, Crete, Greece
| | - Ioannis Peteinarakis
- Interventional Radiology Unit, Radiology Department, University of Crete Medical School, Heraklion, Crete, Greece
| | - Dimitrios Tsetis
- Interventional Radiology Unit, Radiology Department, University of Crete Medical School, Heraklion, Crete, Greece
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Moghadamyeghaneh Z, Sgroi MD, Chen SL, Kabutey NK, Stamos MJ, Fujitani RM. Risk factors and outcomes of postoperative ischemic colitis in contemporary open and endovascular abdominal aortic aneurysm repair. J Vasc Surg 2016; 63:866-72. [DOI: 10.1016/j.jvs.2015.10.064] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 10/14/2015] [Indexed: 10/22/2022]
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Machado R, Teixeira G, Loureiro L, Oliveira P, Almeida R. A idade e o tratamento endovascular do aneurisma da aorta abdominal. Estado da arte. ANGIOLOGIA E CIRURGIA VASCULAR 2016. [DOI: 10.1016/j.ancv.2015.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Otsu M, Ishizaka T, Watanabe M, Hori T, Kohno H, Ishida K, Nakaya M, Matsumiya G. Analysis of anatomical risk factors for persistent type II endoleaks following endovascular abdominal aortic aneurysm repair using CT angiography. Surg Today 2016; 46:48-55. [PMID: 25578204 DOI: 10.1007/s00595-015-1115-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 10/29/2014] [Indexed: 01/13/2023]
Abstract
PURPOSE To predict persistent type II endoleaks (pT2Es) following endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms, we examined factors related to post-EVAR pT2Es. METHODS Eighty-four cases of EVAR were analyzed. T2Es that persisted for ≥6 months were defined as pT2Es. pT2Es flowing from an inferior mesenteric artery (IMA) and lumbar artery (LA) were termed pIMA-T2Es and pLA-T2Es, respectively. The anatomical factors concerning the aneurysm, IMA and LAs were assessed in the preoperative CT angiography images. A statistical analysis was performed on the factors associated with pT2Es. RESULTS The incidence of pT2Es was 25 %. pT2Es were associated with postoperative changes in the aneurysm diameter. A univariate analysis showed that a sac thrombus and the number of patent side branches arising from an aneurysm were significant factors associated with pT2Es. The IMA diameters were significantly larger in cases of pIMA-T2Es. The significant factors associated with pLA-T2Es were a circumferential thrombus, the number of patent LAs and the mean LA diameter. Multivariate analyses indicated that a circumferential thrombus was a protective factor for pT2Es, whereas an IMA ≥2.6 mm and each additional LA branch ≥1.9 mm were powerful risk factors for a pT2E. CONCLUSION Significant anatomical factors associated with pT2E were found in this study. These factors may be useful in selecting patients for perioperative intervention.
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Affiliation(s)
- Masayoshi Otsu
- Department of Cardiovascular Surgery, Chiba Kaihin Municipal Hospital, 3-31-1, Isobe, Mihama-ku, Chiba, Chiba, 261-0012, Japan.
| | - Toru Ishizaka
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Michiko Watanabe
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takaki Hori
- Department of Cardiovascular Surgery, Chiba Nishi General Hospital, Chiba, Japan
| | - Hiroki Kohno
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Keiichi Ishida
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Mitsuru Nakaya
- Department of Cardiovascular Surgery, Chiba Kaihin Municipal Hospital, 3-31-1, Isobe, Mihama-ku, Chiba, Chiba, 261-0012, Japan
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
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Osman E, Tan KT, Tse L, Jaskolka J, Roche-Nagle G, Oreopoulos G, Rubin B, Lindsay T. The in-hospital costs of treating high-risk patients with fenestrated and branched endografts. J Vasc Surg 2015; 62:1457-64. [DOI: 10.1016/j.jvs.2015.07.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 07/07/2015] [Indexed: 01/22/2023]
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Kendrick DE, Miller CP, Moorehead PA, Kim AH, Baele HR, Wong VL, Jordan DW, Kashyap VS. Comparative occupational radiation exposure between fixed and mobile imaging systems. J Vasc Surg 2015; 63:190-7. [PMID: 26454685 DOI: 10.1016/j.jvs.2015.08.062] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/11/2015] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Endovascular intervention exposes surgical staff to scattered radiation, which varies according to procedure and imaging equipment. The purpose of this study was to determine differences in occupational exposure between procedures performed with fixed imaging (FI) in an endovascular suite compared with conventional mobile imaging (MI) in a standard operating room. METHODS A series of 116 endovascular cases were performed over a 4-month interval in a dedicated endovascular suite with FI and conventional operating room with MI. All cases were performed at a single institution and radiation dose was recorded using real-time dosimetry badges from Unfors RaySafe (Hopkinton, Mass). A dosimeter was mounted in each room to establish a radiation baseline. Staff dose was recorded using individual badges worn on the torso lead. Total mean air kerma (Kar; mGy, patient dose) and mean case dose (mSv, scattered radiation) were compared between rooms and across all staff positions for cases of varying complexity. Statistical analyses for all continuous variables were performed using t test and analysis of variance where appropriate. RESULTS A total of 43 cases with MI and 73 cases with FI were performed by four vascular surgeons. Total mean Kar, and case dose were significantly higher with FI compared with MI. (mean ± standard error of the mean, 523 ± 49 mGy vs 98 ± 19 mGy; P < .00001; 0.77 ± 0.03 mSv vs 0.16 ± 0.08 mSv, P < .00001). Exposure for the primary surgeon and assistant was significantly higher with FI compared with MI. Mean exposure for all cases using either imaging modality, was significantly higher for the primary surgeon and assistant than for support staff (ie, nurse, radiology technologist) beyond 6 feet from the X-ray source, indicated according to one-way analysis of variance (MI: P < .00001; FI: P < .00001). Support staff exposure was negligible and did not differ between FI and MI. Room dose stratified according to case complexity (Kar) showed statistically significantly higher scattered radiation in FI vs MI across all quartiles. CONCLUSIONS The scattered radiation is several-fold higher with FI than MI across all levels of case complexity. Radiation exposure decreases with distance from the radiation source, and is negligible outside of a 6-foot radius. Modern endovascular suites allow high-fidelity imaging, yet additional strategies to minimize exposure and occupational risk are needed.
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Affiliation(s)
- Daniel E Kendrick
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals-Case Medical Center, Cleveland, Ohio
| | - Claire P Miller
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals-Case Medical Center, Cleveland, Ohio
| | - Pamela A Moorehead
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals-Case Medical Center, Cleveland, Ohio
| | - Ann H Kim
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals-Case Medical Center, Cleveland, Ohio
| | - Henry R Baele
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals-Case Medical Center, Cleveland, Ohio
| | - Virginia L Wong
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals-Case Medical Center, Cleveland, Ohio
| | - David W Jordan
- Department of Radiology, University Hospitals-Case Medical Center, Cleveland, Ohio
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, University Hospitals-Case Medical Center, Cleveland, Ohio.
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Transcatheter Embolisation of Proximal Type 1 Endoleaks Following Endovascular Aneurysm Sealing (EVAS) Using the Nellix Device: Technique and Outcomes. Cardiovasc Intervent Radiol 2015; 38:1137-42. [DOI: 10.1007/s00270-015-1171-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/29/2015] [Indexed: 10/23/2022]
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Dattani N, Wild J, Sidloff D, Fishwick G, Bown M, Choke E, Sayers R. Outcomes Following Limb Crossing in Endovascular Aneurysm Repairs. Vasc Endovascular Surg 2015; 49:52-7. [DOI: 10.1177/1538574415587512] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Crossing the limbs of the stent during endovascular aneurysm repair (EVAR) is often used to aid cannulation of the contralateral limb. This study assessed outcomes following the use of this technique. Methods: Retrospective review of crossed (n = 43) and uncrossed (n = 269) EVARs was performed at a tertiary vascular center over 5 years. Primary end points were graft limb occlusion (GLO), endoleak, and sac expansion rates. Indications for limb crossing were also assessed. Results: Two-year GLO ( P = .34) and type 1 endoleak ( P = .413) rates were similar between groups. Patients undergoing crossed EVAR experienced more type 2 endoleaks ( P = .002) at 24 months but no increase in sac expansion rates was observed ( P = .275). Thirty-day ( P = .57) and late ( P = .268) mortalities were similar between groups. The main indication for limb crossing was distal aortic angulation (48.8%). Conclusions: Crossed EVAR does not increase the risk of GLOs or clinically significant endoleaks. Further studies are needed to determine the effect on type 2 endoleak rates.
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Affiliation(s)
- Nikesh Dattani
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - John Wild
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - David Sidloff
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Guy Fishwick
- Department of Interventional Radiology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Matthew Bown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Edward Choke
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Robert Sayers
- Department of Interventional Radiology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
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Unibody Endografts for Abdominal Aortic Aneurysm Repair Reduce Radiation and Nephrotoxic Exposure Compared with Modular Endografts. Ann Vasc Surg 2015; 29:751-7. [DOI: 10.1016/j.avsg.2014.11.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 11/09/2014] [Accepted: 11/10/2014] [Indexed: 12/20/2022]
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Fitridge RA, Boult M, Mackillop C, De Loryn T, Barnes M, Cowled P, Thompson MM, Holt PJ, Karthikesalingam A, Sayers RD, Choke E, Boyle JR, Forbes TL, Novick TV. International Trends in Patient Selection for Elective Endovascular Aneurysm Repair: Sicker Patients with Safer Anatomy Leading to Improved 1-Year Survival. Ann Vasc Surg 2015; 29:197-205. [DOI: 10.1016/j.avsg.2014.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 08/25/2014] [Accepted: 09/16/2014] [Indexed: 10/24/2022]
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Dean A, Yap SL, Bhamidipaty V, Pond F. External aortic wrap for repair of type 1 endoleak. Int J Surg Case Rep 2014; 5:739-42. [PMID: 25217878 PMCID: PMC4189073 DOI: 10.1016/j.ijscr.2014.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 07/03/2014] [Accepted: 08/10/2014] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Type 1 endoleak is a rare complication after endovascular abdominal aortic aneurysm repair (EVAR) with a reported frequency up to 2.88%. It is a major risk factor for aneurysmal enlargement and rupture. PRESENTATION OF CASE We present a case of a 68 year old gentleman who was found to have a proximal type 1 endoleak with loss of graft wall apposition on routine surveillance imaging post-EVAR. An initial attempt at endovascular repair was unsuccessful. Given the patient's multiple medical co-morbidities, which precluded the possibility of conventional graft explantation and open repair, we performed a novel surgical technique which did not require aortic cross-clamping. A double-layered Dacron wrap was secured around the infra-renal aorta with Prolene sutures, effectively hoisting the posterior bulge to allow wall to graft apposition and excluding the endoleak. Post-operative CT angiogram showed resolution of the endoleak and a stable sac size. DISCUSSION Several anatomical factors need to be considered when this technique is proposed including aortic neck angulation, position of lumbar arteries and peri-aortic venous anatomy. While an external wrap technique has been investigated sporadically for vascular aneurysms, to our knowledge there is only one similar case in the literature. CONCLUSION Provided certain anatomical features are present, an external aortic wrap is a useful and successful option to manage type 1 endoleak in high-risk patients who are unsuitable for aortic clamping.
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Affiliation(s)
- Anastasia Dean
- Department of Vascular Surgery, Western Hospital, Gordon Street, Footscray, VIC 3011, Australia.
| | - Swee Leong Yap
- Department of Vascular Surgery, Western Hospital, Gordon Street, Footscray, VIC 3011, Australia
| | - Venu Bhamidipaty
- Department of Vascular Surgery, Western Hospital, Gordon Street, Footscray, VIC 3011, Australia
| | - Franklin Pond
- Department of Vascular Surgery, Western Hospital, Gordon Street, Footscray, VIC 3011, Australia
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3D Contrast Enhanced Ultrasound for Detecting Endoleak Following Endovascular Aneurysm Repair (EVAR). Eur J Vasc Endovasc Surg 2014; 47:487-92. [DOI: 10.1016/j.ejvs.2014.02.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 02/03/2014] [Indexed: 10/25/2022]
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Vallabhaneni R, Farber MA, Schneider F, Ricco JB. Debate: Whether young, good-risk patients should be treated with endovascular abdominal aortic aneurysm repair. J Vasc Surg 2013; 58:1709-15. [DOI: 10.1016/j.jvs.2013.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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50
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Vallabhaneni R, Farber M. Part One: For the Motion. Young Patients with Good Risk Factors Should be Treated with EVAR. Eur J Vasc Endovasc Surg 2013; 46:614-7. [DOI: 10.1016/j.ejvs.2013.09.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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