Midterm results of adjunctive neck therapies performed during elective infrarenal aortic aneurysm repair

Adjunctive Procedures for Challenging Endovascular Abdominal Aortic Repair: When Needed and How Effective?

Endovascular aneurysm repair (EVAR) is now considered the first choice treatment modality for abdominal aortic aneurysm (AAA) treatment. Advocates for endovascular strategies will try to treat all AAA by EVAR, regardless if the anatomy is conducive for treatment or not. However, the long-term outcomes of EVAR outside the instructions for use (IFU) due to a hostile aneurysmal neck or iliac artery anatomy are known to be poor. The EVAR procedures can be classified according to the technical difficulty, IFU, and need for visceral revascularization: standard, adjunctive, and complex EVAR. The situation required for adjunctive procedures can be classified as the following four steps: a hostile neck (i.e., short or severely angled); large inferior mesenteric or lumbar artery; tough iliac artery anatomy, such as a short common iliac artery and stenotic external iliac artery; and limitations in vascular access. This article will discuss the adjunctive procedures to overcome hostile aneurysm neck and unsuitable iliac artery anatomy.

Conservative management of type 1A endoleaks at completion angiogram in endovascular repair of infra-renal abdominal aortic aneurysms with current generation stent grafts

Purpose

Proximal type 1A endoleaks on completion intra-operative angiography are not infrequently seen following endovascular abdominal aneurysm repair (EVAR). The natural course of these leaks is not well established. We sought to determine the rate of spontaneous resolution and a conservative treatment approach to these endoleaks.

Methods

All cases involving endovascular repairs of infra-renal abdominal aortic aneurysms resulting in proximal type 1A endoleak on final intra-operative completion angiography were retrospectively reviewed from 1 April 2010 and 30 March 2015. Demographic, pre and post-procedural imaging, and clinical outcomes were reviewed. Summarizing descriptive statistics are reported.

Results

Of the 337 patients who underwent an EVAR, 24 patients (7.1%) had a proximal type 1A endoleak on final intra-operative angiography. Twenty-two of 24 patients (92%) with proximal type 1A endoleaks had spontaneous resolution on follow-up imaging without any intervention, while two (8%) patients had a persistent endoleak. One of these patients required intervention. The median follow-up for patients with resolved endoleaks was 2.5 years vs. 4 and 6 years, respectively, for patients that did not resolve spontaneously.

Conclusion

A conservative approach may be used in the management of patients with proximal type 1A endoleaks on completion angiography once maximum proximal seal was achieved intra-operatively as the vast majority of these leaks spontaneously seal.

Management of Immediate Post-Endovascular Aortic Aneurysm Repair Type Ia Endoleaks and Late Outcomes

BACKGROUND

Post-endovascular aortic aneurysm repair (EVAR) endoleaks and the need for reintervention are challenging. Additional endovascular treatment is advised for type Ia endoleaks detected on post-EVAR completion angiogram. This study analyzed management and late outcomes of these endoleaks.

STUDY DESIGN

This was a retrospective review of prospectively collected data from EVAR patients during a 10-year period. All post-EVAR type Ia endoleaks on completion angiogram were identified (group A) and their early (30-day) and late outcomes were compared with outcomes of patients without endoleaks (group B). Kaplan-Meier analysis was used for survival analysis, sac expansion, late type Ia endoleak, and reintervention.

RESULTS

Seventy-one of 565 (12.6%) patients had immediate post-EVAR type Ia endoleak. Early intervention (proximal aortic cuffs and/or stenting) was used in 56 of 71 (79%) in group A vs 31 of 494 (6%) in group B (p < 0.0001). Late type Ia endoleak was noted in 9 patients (13%) in group A at a mean follow-up of 28 months vs 10 patients (2%) in group B at a mean follow-up of 32 months (p < 0.0001). Late sac expansion and reintervention rates were 9% and 10% for group A vs 5% and 3% for group B (p = 0.2698 and p = 0.0198), respectively. Freedom rates from late type Ia endoleaks at 1, 3, and 5 years for group A were 88%, 85%, and 80% vs 98%, 98%, and 96% for group B (p < 0.001); and for late intervention, were 94%, 92%, and 77% for group A, and 99%, 97%, and 95% for group B (p = 0.007), respectively. Survival rates were similar.

CONCLUSIONS

Immediate post-EVAR type Ia endoleaks are associated with higher rates of early interventions, late endoleaks and reintervention, which will necessitate strict post-EVAR surveillance.

Anaphylactic Reaction during Implantation of Ovation Abdominal Stent Graft in Patients with Abdominal Aortic Aneurysm

The Ovation Abdominal Stent Graft System is a trimodular endoprosthesis planned to overcome the limitations of currently available stent grafts, allowing complex iliac and femoral access and providing a proximal seal in challenge infrarenal neck morphology. The proximal sealing is achieved by means of a network of inflatable rings filled with low-viscosity radiopaque polyethylene glycol-based polymer during stent-graft deployment. The leakage of polymer outside the channel to fill the rings into the vascular system may induce an hypersensitivity reaction and anaphylactic shock. We report a case of anaphylactic reaction during Ovation Abdominal Stent Graft System implantation. The endovascular procedure was successfully concluded.

Treatment of Hostile Proximal Necks During Endovascular Aneurysm Repair

Endovascular aneurysm repair (EVAR) is a therapy that continues to evolve rapidly as advances in technology are incorporated into new generations of devices and surgical practice. Although EVAR has emerged as a safe and effective treatment for patients with favorable anatomy, treatment of patients with unfavorable anatomy remains controversial and is still an off-label indication for endovascular treatment with some current stent-grafts. The proximal neck of the aneurysm remains the most hostile anatomic barrier to successful endovascular repair with long-term durability. Open surgery for unfavorable necks is still considered the gold standard treatment in contemporary practice, despite the increased mortality and morbidity attributed to suprarenal cross-clamping, particularly in high-risk patients. Evolving technology may overcome the obstacles preventing endovascular treatment of unfavorable proximal neck anatomy; current approaches include purely endovascular as well as hybrid approaches, and generally include strategies that either extend the length of the short neck, move the proximal neck more proximally, or keep the short neck intact. These approaches include the use of debranching techniques, banding, chimneys, fenestrated and branched devices, filling the sac with endobags, endoanchors, and other novel devices. These newer-generation devices appear to have promising short- and midterm results. However, lack of good evidence of efficacy with long-term results for these newer approaches still precludes wide dissemination of endovascular solutions for the hostile proximal neck.

A retrospective review of Palmaz stenting of the aortic neck for endovascular aneurysm repair

BACKGROUND

To review the aortic neck characteristics, graft types, and technical results of Palmaz stent placement as an adjunct to endovascular aneurysm repair (EVAR).

METHODS

A retrospective review of 110 consecutive EVAR cases identified 18 cases in which Palmaz stents were placed as an adjunct to EVAR. Graft types, hostile aortic neck features (neck diameter: >26 mm, length: <15 mm, angulation: >60°, reverse taper necks), and treatment success were identified.

RESULTS

Technical success in the placement of a proximal Palmaz stent was achieved in 17 of 18 cases. Palmaz stenting was attempted for the treatment of type I endoleak in 17 of 18 patients. One prophylactic stent was deployed in the setting of hostile neck anatomy. Proximal stent deployment resulted in immediate treatment success of type I endoleaks in 16 of 17 patients-one failure occurred in a patient who presented with a delayed type I endoleak. Analysis of aortic neck anatomy revealed that two of 18 patients had no criteria for a hostile neck, seven had one criterion, and nine met at least two criteria. With respect to stent-graft types, nine of 18 (50%) cases used the Endologix Powerlink, six used Gore Excluder, two used Cook Zenith, and one used Medtronic Talent. With a mean follow-up of 254 days, 16 of 17 type I endoleaks remain resolved.

CONCLUSIONS

With proper patient selection and additional adjunctive treatments, Palmaz stenting can effectively treat proximal type I endoleaks.