Evaluation of the Endurant stent graft under instructions for use vs off-label conditions for endovascular aortic aneurysm repair

The Enzen Trial: Analysis of EVAR Endoprosthesis Zenith and Endurant for Infrarenal Aortoiliac Aneurysms Regarding Outcomes, Endoleaks, and Reinterventions

OBJECTIVE

The main objective of this paper is to analyze the outcomes regarding endoleaks, reinterventions, and death related to aneurysm complications in patients submitted to endovascular repair (EVAR) for abdominal aortoiliac aneurysm (AAA) using Endurant II (Medtronic) and Zenith Flex (Cook) endografts.

METHODS

This was a prospective, consecutive cohort study of patients with AAA who underwent EVAR between January 2019 and December 2022. Two groups of patients were evaluated: Group Endurant (patients submitted to EVAR with the use of Endurant II) and Group Zenith (patients submitted to EVAR with the use of Zenith Flex).

RESULTS

A total of 156 patients were evaluated. Group Zenith (67 patients, 42.9%) and Group Endurant (89 patients, 57.1%). The perioperative mortality was 5.1%, eight patients (six patients Group Zenith, and two patients Group Endurant, p=0.054). There were 28 patients (17.9%) submitted to urgent repair of the aneurysm (expansion or rupture), with no differences among the groups. There were 36 cases (23.1%) of later endoleak, with a higher incidence in Zenith group (23 patients, 34.3%) than Endurant group (13 patients, 14.6%, p=0.002), most of them Type II endoleak (21 patients, 13.4%). There were 12 cases of Type I endoleak, also with a higher prevalence in Zenith group (13.4%) than Endurant group (3.4%, p=0.002). Moreover, regarding limb graft occlusion (LGO), there were nine patients (5.8%), with a higher prevalence in Zenith group (9%) than Endurant group (3.4%, p=0.045). The overall survival in a Kaplan-Meier at 720 days was 82.3% in the Zenith group and 89.1% in the Endurant group, with no statistical significance among the groups (p=0.09). The freedom from reintervention rates in a Kaplan-Meier at 720 days was 82.8% in the Zenith group and 93.2% in the Endurant group (p=0.001).

CONCLUSION

In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, LGO and reinterventions than patients submitted to Endurant II endografts. The linear regression analysis showed that the presence of endoleaks, type of endograft device (Zenith graft) and limb graft occlusion were related to higher reintervention rates.

CLINICAL IMPACT

In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, limb graft occlusions and reinterventions than patients submitted to Endurant II endografts. The main impact and the innovation that this article provides is an opportunity to evaluate and choose the best endograft suitable for the patient with AAA during EVAR.

Friendly Neck Anatomy Does Not Prevent Neck-Related Adverse Events After EVAR

BACKGROUND

Life-long follow-up after endovascular aneurysm repair (EVAR) is costly and burdensome to the patient. Follow-up should be stratified based on the risk of EVAR failure. Aneurysm neck is thought to be the single most important risk factor. This study investigated neck anatomy as a predictor of neck-related adverse events after EVAR.

METHODS

This retrospective single-center study included consecutive patients undergoing elective EVAR for infrarenal abdominal aortic aneurysms between 2011 and 2016 (n = 222) who were followed with yearly imaging until December 2020. Hostile neck was defined as neck length ≤15 mm, width ≥28 mm, angulation ≥60°, calcification, or thrombus ≥50% of circumference or conical neck based on preoperative computed tomography angiography. Neck-related adverse event was defined as aneurysm rupture, any neck-related reintervention or type 1a endoleak during follow-up.

RESULTS

Ninety (41%) patients had hostile neck and 132 (59%) had friendly neck. There were no differences in 30-day mortality (1% vs. 1%, P = 0.78), major adverse events (20% vs. 16%, P = 0.43) or reinterventions during the hospital stay (8% vs. 4%, P = 0.20) between patients with hostile and friendly neck. Estimated survival at 1 year was 89 ± 3% for hostile neck and 95 ± 2% for friendly neck patients (P < 0.01). Five-year survival estimates were 51 ± 6% and 66 ± 4%, respectively. Aneurysm-related mortality was higher after 6 years in patients with hostile neck (P < 0.01). Twenty-four patients (11%) suffered neck-related adverse events with mean time-to-event of 3.3 ± 2.8 years; there were no differences between the groups stratified by neck anatomy. Incidentally, preoperative aneurysm diameter was found to be an independent risk factor for neck-related adverse events and aneurysm-related mortality; 53 patients (24%) had aneurysm diameter ≥70 mm, which was associated with nearly 4-fold risk of neck-related complications during the follow-up.

CONCLUSIONS

Friendly neck anatomy may not protect from neck-related adverse events after EVAR in the long-term. Especially patients with large aneurysms should be followed closely.

Mid-term results of "off-label" use of the Endurant stentgraft in patients with infrarenal abdominal aortic aneurysms

OBJECTIVES

EVAR is the preferred treatment modality for patients with an infrarenal abdominal aortic aneurysm with suitable anatomy. Each manufacturer of aortic stentgrafts has specific anatomic requirements. In some patients, it is not possible to adhere to the instructions for use, but alternative treatment is also not possible. In these patients, EVAR can be performed outside instructions for use.

METHODS

In this study, all consecutive patients in whom an Endurant II or IIS stentgraft was used between 1 January and 31 December were reviewed. We compared the two patient groups in whom this stentgrafts was used outside and inside instructions for use. Patients with planned adjuvant therapy, for example, chimney procedure or iliac side branches, were excluded.

RESULTS

In 74 of 178 (41.6%) patients, the instructions for use were not adhered. The main reason was pathology of the aortic neck. There were more patients with type IA endoleak, this difference was borderline significant (p = .06). There were more patients with limb occlusion in the early postoperative period, but at the end of the follow-up period, the incidence was comparable. Aneurysm-related mortality and all-cause mortality were comparable in both groups.

CONCLUSION

In this study, real-life experience with the Endurant II and IIS stentgraft is described. Non-adherence with instructions for use was associated with a higher risk of endoleak type IA (p = .06). In the early postoperative period, there were more patients with limb occlusion; this finding was not observed anymore at the end of the follow-up period.

Computational prediction of proximal sealing in endovascular abdominal aortic aneurysm repair with unfavorable necks

BACKGROUND AND OBJECTIVE

Endovascular aortic aneurysm repair (EVAR) has become the standard treatment for abdominal aortic aneurysms in most centers. However, proximal sealing complications leading to endoleaks and migrations sometimes occur, particularly in unfavorable aortic anatomies and are strongly dependent on biomechanical interactions between the aortic wall and the endograft. The objective of the present work is to develop and validate a computational patient-specific model that can accurately predict these complications.

METHODS

Based on pre-operative CT-scans, we developed finite element models of the aorta of 10 patients who underwent endovascular aortic aneurysm repair, 7 with standard morphologies and 3 with unfavorable anatomies. We simulated the deployment of stent grafts in each aorta by solving mechanical equilibrium with a virtual shell method. Eventually we compared the actual stent ring positions from post-operative computed-tomography-scans with the predicted simulated positions.

RESULTS

A successful deployment simulation could be performed for each patient. Relative radial, transverse and longitudinal deviations were 6.3 ± 4.4%, 2.5 ± 0.9 mm and 1.4 ± 1.1 mm, respectively.

CONCLUSIONS

The numerical model predicted accurately stent-graft positions in the aortic neck of 10 patients, even in complex anatomies. This shows the potential of computer simulation to anticipate possible proximal endoleak complications before EVAR interventions.

Influence of Patient Anatomy on Intraoperative Radiation Exposure and Operation Time during Standard EVAR

Endovascular aortic repair (EVAR) is the primary treatment for abdominal aortic aneurysms (AAAs). To optimise patient safety during the standard EVAR procedure, we aimed to investigate the influence of patient anatomy on intraoperative radiation exposure and surgical time. This retrospective study comprised 90 patients (mean age 73.4 ± 8.2 years; 92.2% male) with an infrarenal aortic aneurysm who underwent a standard EVAR procedure. The relationships between dose area product, operating time, and anatomical conditions were investigated in preoperative computed tomography angiography using open-source software. Logistic regression analysis indicated that only body mass index (BMI) had predictive value for radiation exposure. The accuracy of the model was 98.67%, with an area under the curve of 0.72. The duration of surgery was significantly correlated with an increased BMI (odds ratio (OR) = 1.183; p < 0.05), the tortuosity of AAAs (OR = 1.124; p < 0.05), and the left common iliac artery (OR = 1.028; p < 0.05). Thus, BMI impacts the prediction of intraoperative radiation exposure more significantly than the anatomical characteristics of the infrarenal aorta and iliac arteries, and the duration of surgery significantly correlates with both BMI and the tortuosity of the infrarenal aorta and iliac arteries.

The Correlation of Aortic Neck Angle and Length in Abdominal Aortic Aneurysm with Severe Neck Angulation for Prediction of Intraoperative Neck Complications and Postoperative Outcomes after Endovascular Aneurysm Repair

OBJECTIVES

Endovascular aneurysm repair (EVAR) in a hostile neck has been associated with adverse outcomes. We aimed to determine the association of infrarenal aortic neck angle and length and establish an optimal cutoff value to predict intraoperative neck complications and postoperative outcomes.

METHODS

This was a retrospective review of patients with an intact infrarenal abdominal aortic aneurysm (AAA) with severe neck angulation (>60 degrees) who underwent EVAR from October 2010 to October 2018. Demographic data, aneurysm morphology, and operative details were collected. The ratio of neck angle and length was calculated as the optimal cutoff value of the aortic neck angle-length index. The patients were categorized into two distinct groups using latent profile analysis, a statistical technique employed to identify concealed subgroups within a larger population by examining a predetermined set of variables. Intraoperative neck complications, adjunct neck procedures, and early and late outcomes were compared.

RESULTS

115 patients were included. Group 1 (G1) had 95 patients with an aortic neck angle-length index ≤ 4.8, and Group 2 (G2) had 20 patients with an aortic neck angle-length index > 4.8. Demographic data and aneurysm morphology were not significantly different between groups except for neck length (p < 0.001). G2 had more intraoperative neck complications than G1 (21.1% vs. 55%, p = 0.005). Adjunctive neck procedures were more common in G2 (18.9% vs. 60%, p < 0.001). The thirty-day mortality rate was not statistically different. G1 patients had a 5-year proximal neck re-intervention-free rate comparable to G2 patients (93.7% G1 vs. 87.5% G2, p = 0.785). The 5-year overall survival rate was not statistically different (59.9% G1 vs. 69.2% G2, p = 0.891).

CONCLUSIONS

Patients with an aortic neck angle-length index > 4.8 are at greater risk of intraoperative neck complications and adjunctive neck procedures than patients with an aortic neck angle-length index ≤ 4.8. The 5-year proximal neck re-intervention-free rate and the 5-year survival rate were not statistically different. Based on our findings, this study suggests that the aortic neck angle-length index is a reliable predictor of intraoperative neck complications during EVAR in AAA with severe neck angulation.

Long-term outcomes of the Endurant endograft in patients undergoing endovascular abdominal aortic aneurysm repair

OBJECTIVE/BACKGROUND

To investigate the long-term outcomes after endovascular aneurysm repair (EVAR) in a real-world setting using the Endurant endograft (EG).

METHODS

184 EVAR candidates treated with the Endurant family EGs in a single vascular center were prospectively enrolled from January 2009 to December 2016. Kaplan-Meir estimates of long-term standardized primary and secondary outcome measures were performed. Per protocol, subgroup comparison analysis was performed in three groups: patients treated within instructions for use (in-IFU) vs patients treated outside IFU (outside-IFU), EVAR in patients receiving the Endurant proximal diameter 32 or 36 mm EG vs those receiving the <32 mm diameter EG and EVAR with various Endurant EG versions.

RESULTS

The mean follow-up was 75.09 ± 37.9 months (range: 4.1-172 months). The median age of the patients was 72.96 ± 7.03 years (range: 55-88 years). A total of 177 patients were male (96.2%). Compliance with IFU was followed in 107 patients (58.2%). Overall survival was 69.5% and 48% at 5 and 8 years, respectively. Of the 102 all-cause deaths, 7 (6.9%) were aneurysm related. Six of these postimplant deaths occurred in patients presented with aneurysm rupture from type Ia or/and type Ib endoleak. At 5, 8, and 10 years of observation, freedom from aneurysm rupture, open surgical conversion, type I/III endoleak, any type of endoleak, aneurysm-related secondary intervention probabilities, and neck-related events were as follows: 98.1%, 95%, and 89.4%; 95.1%, 91.2%, and 85.7%; 93.6%, 87.3%, and 83.9%; 83.4%, 74%, and 70.9%; 89.8%, 76.7%, and 72%; and 96.3%, 90%, and 87.6%, respectively. Corresponding clinical success was 90%, 77.4%, and 68.4%, respectively. Patients treated outside-IFU had significantly higher risk of aneurysm rupture, open surgical conversion probability, occurrence of type I/III endoleak, and chance of reinterventions and lower clinical success probabilities compared with the in-IFU counterparts at 5 and 8 years. This statistical difference remained when type Ia endoleak or endoleak of any type was considered independently. In addition, it was stronger in patients having extreme anatomic boundaries (>1 hostile anatomic condition), when aneurysm-related death, aneurysm rupture, and clinical success at 5 years were considered. Overall proximal migration and limb occlusion were recorded in 1.1% and 4.9% of the patients, respectively. Overall reintervention rate was 17.4%. An increase in aneurysm sac diameter was observed in 12.5% of patients and was not related to IFU status. The Endurant version or the proximal EG diameter had no significant association with the chance of any complication or adverse event.

CONCLUSIONS

The data confirmed the durability of the Endurant EG, achieving promising long-term outcomes in a real-world setting. However, its positive performance must be interpreted with caution in patients treated off-label especially those with extreme anatomic boundaries. In this cohort, some of EVAR advantages might be lost in the late future. Further similar studies are warranted.

Endovascular aneurysm repair offers a survival advantage and is cost-effective compared with conservative management in patients physiologically unfit for open repair

OBJECTIVE

The endovascular aneurysm repair-2 (EVAR-2) trial suggested that EVAR in patients unfit for open surgical repair (OSR) failed to provide a significant overall survival advantage compared with conservative management. The aim is to compare survival and cost-effectiveness in patients with poor cardiopulmonary exercise test (CPET) metrics who underwent EVAR or were managed conservatively.

METHODS

A prospective database of all CPETs (1435 patients) performed to assess preoperative fitness for abdominal aortic aneurysm repair was maintained. A total of 350 patients deemed unfit for OSR underwent EVAR or were managed conservatively. A 1:1 propensity-matched analysis incorporating age, gender, anaerobic threshold, and aneurysm size was used to compare survival. Cost-effectiveness analysis was based on the economic model for the National Institute for Health and Care Excellence clinical guideline on abdominal aortic aneurysm treatment.

RESULTS

Propensity matching produced 122 pairs of patients in the EVAR and conservative management groups. The median overall survival for the EVAR group was significantly longer than that for the conservative management group (84 vs 30 months, P < .001). One-, three-, and five-year mortality in the EVAR group was 7%, 40%, and 68%, respectively, compared with 25%, 68%, and 82% in the conservative management group, all P < .001. The increment cost-effectiveness ratio for EVAR was £8023 (US$11,644) per quality-adjusted life year gained compared with £430,602 (US$624,967) in the National Institute for Health and Care Excellence guideline, which is based on EVAR-2 results.

CONCLUSIONS

EVAR offers a survival advantage and is cost-effective in selected patients deemed unfit for OSR based on CPET compared with conservative management.

Is Evar Feasible in Challenging Aortic Neck Anatomies? A Technical Review and Ethical Discussion

Background: Endovascular aneurysm repair (EVAR) has become an accepted alternative to open repair (OR) for the treatment of abdominal aortic aneurysm (AAA) despite “hostile” anatomies that may reduce its effectiveness. Guidelines suggest refraining from EVAR in such circumstances, but in clinical practice, up to 44% of EVAR procedures are performed using stent grafts outside their instruction for use (IFU), with acceptable outcomes. Starting from this “inconsistency” between clinical practice and guidelines, the aim of this contribution is to report the technical results of the use of EVAR in challenging anatomies as well as the ethical aspects to identify the criteria by which the “best interest” of the patient can be set. Materials and Methods: A literature review on currently available evidence on standard EVAR using commercially available endografts in patients with hostile aortic neck anatomies was conducted. Medline using the PubMed interface and The Cochrane Library databases were searched from 1 January 2000 to 6 May 2021, considering the following outcomes: technical success; need for additional procedures; conversion to OR; reintervention; migration; the presence of type I endoleaks; AAA-related mortality rate. Results: A total of 52 publications were selected by the investigators for a detailed review. All studies were either prospective or retrospective observational studies reporting the immediate, 30-day, and/or follow-up outcomes of standard EVAR procedures in patients with challenging neck anatomies. No randomized trials were identified. Fourteen different endo-grafts systems were used in the selected studies. A total of 45 studies reported a technical success rate ranging from 93 to 100%, and 42 the need for additional procedures (mean value of 9.04%). Results at 30 days: the incidence rate of type Ia endoleak was reported by 37 studies with a mean value of 2.65%; 31 studies reported a null migration rate and 32 a null conversion rate to OR; in 31 of the 35 studies that reported AAA-related mortality, the incidence was null. Mid-term follow-up: the incidence rate of type Ia endoleak was reported by 48 studies with a mean value of 6.65%; 30 studies reported a null migration rate, 33 a null conversion rate to OR, and 28 of the 45 studies reported that the AAA-related mortality incidence was null. Conclusions: Based on the present analysis, EVAR appears to be a safe and effective procedure—and therefore recommendable—even in the presence of hostile anatomies, in patients deemed unfit for OR. However, in order to identify and pursue the patient’s best interest, particular attention must be paid to the management of the patient’s informed consent process, which—in addition to being an essential ethical-legal requirement to legitimize the medical act—ensures that clinical data can be integrated with the patient’s personal preferences and background, beyond the therapeutic potential of the proposed procedures and what is generically stated in the guidelines.

Five-year outcomes of the Bi- versus Trimodular EndurantTM stent-graft in 100 patients with infrarenal abdominal aortic repair

BACKGROUND

Recent studies on the Endurant™ endografts mainly compared outcomes of the bimodular stent-graft to other manufacturer's endografts or reported results for cases outside manufacturer's instructions for use (IFU), while data on the experience of standard endovascular aortic repair (EVAR) of infrarenal abdominal aortic aneurysms (AAA) inside manufacturer's IFU comparing the bi- with the trimodular device is limited.

METHODS

Inclusion criteria were: 1) infrarenal aneurysms (>50 mm diameter) treated by Endurant^TM II (END II) or Endurant^TM IIs (END IIs) stent-graft inside manufacturer's IFU; 2) available CTA with 1 mm reconstruction of the entire aorta prior to intervention. Endpoints comparing the devices included technical success, 30-day mortality, rate of complications (bleeding with conversion to open repair, stent-graft stenosis/occlusion, acute distal embolism, infection or postprocedural necessity of dialysis), endoleaks and reinterventions (5-year follow-up). Aneurysm sac diameters were compared between baseline preinterventional CTA and last post-interventional CTA.

RESULTS

One hundred patients (90% male, mean age 74 years) treated with END II (N.=66) or END IIs (N.=34) were included. Technical success was 99%. One procedure-related active bleeding occurred ending up in surgical conversion (END II N.=1). 30d mortality was 0%. No initial type I/III endoleaks were present. Re-interventions were required in 19/100 (19%) of patients (END II N.=10; END IIs N.=9, P=0.17). The outcome of EVAR including technical success, 30d mortality, rate of complications, endoleaks and re-interventions showed no significant differences comparing END II/IIs.

CONCLUSIONS

Five-year outcomes of EVAR show consistently safe and effective results for either END II or IIs device.

Long-term outcomes of endovascular aneurysm repair according to instructions for use adherence status

OBJECTIVE

Endovascular aneurysm repair (EVAR) has become a standard treatment method for abdominal aortic aneurysms (AAA). Endovascular device manufacturers have defined specific anatomic criteria for aneurysm characteristics to be observed as instructions for use (IFU) with specific grafts. In clinical practice, the prevalence of performing EVAR outside the IFU is high. This study aims to determine the impact of IFU criteria non-adherence on outcomes.

METHODS

Patients undergoing EVAR for an infrarenal AAA between 2005 and 2013 were included. IFU non-adherence was defined as any violation of device-specific IFU criteria and was compared to IFU adherence. Primary outcomes were all-cause mortality, aneurysm-related mortality, AAA ruptures, graft-related adverse events (GRAEs), including limb-related adverse events, and type Ia endoleaks. Secondarily, the aim was to study whether the prevalence of EVAR performed outside the IFU has increased over time.

RESULTS

A total of 258 patients were included, 144 (55.8%) of whom were treated according to the IFU criteria and 114 (44.2%) outside the criteria. In the IFU non-adherence group, all-cause mortality (HR 1.39, 95% CI 1.02-1.89, p = .037) and aneurysm-related mortality (HR 5.1, 95% CI 1.4-18.6, p = .015) were higher, as were the incidences of AAA ruptures (HR 5.4, 95 % CI 1.1-26.6, p = .036) and GRAEs (HR 1.7, 95% CI 1.1-2.8, p = .025). No significant association was found between type Ia endoleak and neck-related IFU or limb-related adverse events and iliac-related IFU. However, neck length was a risk factor for a type Ia endoleak (HR 18.2, 95% CI 6.3-52.2, p < .001), aneurysm-related mortality (HR=8.7, 95% CI 1.8-41.6, p = .007), rupture (HR= 21.7, 95% CI 2.8-166, p = .003), and GRAEs (HR 4.4, 95% CI 2.0-9.7, p < .001). An IFU violation regarding the neck angulation was also a risk factor for all-cause mortality (HR 2.0, 95% CI 1.1-3.7, p = .032), aneurysm-related mortality (HR 7.6, 95% CI 1.4-42.8, p = .021), AAA rupture (HR 79.4, 95% CI 6.3-999, p = .001), and GRAEs (HR 4.3, 95% CI 1.9-9.5, p < .001). The prevalence of EVAR performed outside the IFU did not increase over time.

CONCLUSIONS

Performing EVAR outside the IFU has a negative effect on outcomes, including all-cause mortality, aneurysm-related mortality, ruptures, and graft-related adverse events. Neck angulation and neck length seem to be the most crucial aneurysm characteristics.

New Morphological Factor for Predicting Late Proximal Type I Endoleak after Endovascular Aneurysm Repair

BACKGROUND

Although we have witnessed several cases of late proximal type I endoleak (T1AEL) after endovascular aneurysm repair (EVAR), most patients did not have "hostile neck" preoperatively. We hypothesized that the distance between the lowest renal artery and the neck angulation point and neck length are the 2 most important factors for maintaining long-term proximal sealing. This study evaluated "neck hostility," which is the product of the distance to the angulation point and the neck length, as a preoperative morphological risk factor for the development of late T1AEL after EVAR.

METHODS

A retrospective review of a prospectively assembled database was performed for all patients who had undergone EVAR at a single institution from June 2007 to May 2017. Patient demographics and preoperative imaging data were collected, and Cox regression analysis was performed to identify the risk factors for late T1AEL.

RESULTS

Of the 655 patients who underwent EVAR during the study period, 115 were excluded due to complex EVAR (n = 14), primary indications for iliac aneurysms (n = 86), primary T1AEL (n = 3), or other reasons (n = 15). Of the remaining 537 patients, twelve patients (2.2%) developed late T1AEL a median of 3.2 (interquartile range [IQR]; 3.0, 5.4) years after EVAR. Receiver operating characteristic (ROC) curve analysis revealed a neck hostility cutoff value of 8. Cox regression analysis revealed that a neck hostility value ≤8 and conical neck anatomy were risk factors for the development of late T1AEL after EVAR. Well-known hostile neck factors such as short neck, severe angulated neck, and severe calcification/thrombus in the proximal neck were not significantly different.

CONCLUSIONS

The present study demonstrated a correlation between late T1AEL and the product of the angulation distance and the neck length. This factor may be useful for predicting poor late proximal outcomes after EVAR.

Simple diameter measurements with ultrasound can be safely used to follow the majority of patients after infrarenal endovascular aneurysm repair

BACKGROUND

The optimal imaging follow-up after infrarenal EVAR is still undefined. The objective was to study the outcome of a personalized follow-up program after infrarenal EVAR based on ultrasound AAA diameter measurements for low-risk patients.

METHODS

All consecutive patients followed-up locally after elective and acute infrarenal EVAR between 2010 and 2015 were retrospectively reviewed. Patients underwent CTA at 1 month post-EVAR whereby the attending surgeon defined the subsequent follow-up. Patients considered at low risk were followed with ultrasound only assessing AAA diameter at 1, 2, 3 and every 5 years postoperatively (group A). Low-risk required a favourable preoperative anatomy especially regarding the aneurysm neck, satisfactory intraoperative result and uneventful 1 month CTA (type 2 endoleaks acceptable). Patients not fulfilling the criteria for group A were followed with yearly 3-phase-CTAs (group B).

RESULTS

222 patients with a AAA median diameter of 58 (54-68) mm were included. 191 were allocated into group A and 31 in group B. Median follow-up time was 36 (24-59) months. Five year primary and primary assisted success was 82 ± 5 % and 93 ± 3 % for group A and 70 ± 13% and 93 ± 5% for group B, respectively (P= 0.042 and P= 0.504, respectively). 16 late aneurysm-related re-interventions were performed in 12 patients (7 in group A and 9 in group B). In group A, 5 re-interventions were rupture-preventing and 2 were symptomatic. All late re-interventions in group B were performed following findings on follow-up imaging. Five-year late re-intervention-free survival was 95 ± 2 % and 84 ± 7 % for groups A and B, respectively (P=0.046). Five-year survival was 80 ± 3 % and 63 ± 10 % for group A and B, respectively (P= 0.024).

CONCLUSIONS

A customized follow-up program after infrarenal EVAR based on ultrasound AAA diameter measurements in low-risk patients seems to be effective in maintaining a very high mid-term clinical success rate.

Outcomes of thoracic endovascular aortic repair in thoracic aortic aneurysm and penetrating aortic ulcer using the Conformable Gore TAG within and outside the instructions for use

OBJECTIVE

To describe the outcome of thoracic endovascular aortic repair (TEVAR) in thoracic aortic aneurysm and penetrating aortic ulcer with respect to instructions for use status.

METHODS

Between October 2009 and September 2017, a total of 532 patients underwent TEVAR; of which 195 have been treated using the Conformable GORE® TAG® thoracic endoprosthesis (CTAG). Fifty-six patients of this cohort underwent TEVAR for thoracic aortic aneurysm/penetrating aortic ulcer using the CTAG. Depending on the preoperative computed tomography angiography findings, patients were classified as inside or outside the device's instructions for use. All inside instruction for use patients underwent postoperative reclassification regarding the instructions for use status. Study endpoints included TEVAR-related reintervention, exclusion of the pathology (endoleak type I/III), TEVAR-related mortality, and graft-related serious adverse events. The median duration of follow-up was 29.7 months (range: 0-109.4 months).

RESULTS

Of the 56 patients, 17 were primarily classified as outside instruction for use, and in additional 13 patients, TEVAR was performed outside instruction for use, leading to 30 outside instruction for use patients (53.6%). Twenty-six patients (46.4%) were treated inside instruction for use. Reintervention-free survival was lower in outside instruction for use patients (P = 0.016) with a hazard ratio of 9.74 (confidence interval 1.2-80.2; P = 0.034) for TEVAR-related reintervention. With respect to endoleak type I/III, relevant difference was detected between inside/outside instruction for use status (P = 0.012). The serious adverse event rate was 30.4%, mainly in outside instruction for use patients (P = 0.004). Logistic regression analysis indicated an association between graft-related serious adverse event/instructions for use status (odds ratio 6.11; confidence interval 1.6-30.06; P = 0.012). In-hospital death was seen more frequently in outside instruction for use patients (P = 0.12) as was procedure-related death (log-rank test: P = 0.21).

CONCLUSION

TEVAR for thoracic aortic aneurysm/penetrating aortic ulcer is frequently performed outside instruction for use despite preoperative inside instruction for use eligibility, leading to important consequences for technical/clinical outcome. Instructions for use adherence in TEVAR should be of interest for further large-scale studies.

Endovascular aortic repair with the Gore Excluder Conformable endograft in severe neck angulation: Preliminary experience and technical aspects

OBJECTIVES

Endovascular procedures are now the standard of care for endovascular aortic aneurysm repair but treatment of hostile proximal neck anatomy is still challenging. New endografts were brought to the market specifically designed to accommodate severe neck angulation. Authors describe a preliminary experience and early results using the Gore Excluder Conformable endograft (W. L. Gore & Associates, Flagstaff, Ariz) and its active control system in severe neck angulation with a standardized technical approach to achieve precise deployment in this hostile anatomy.

METHODS

From June 2019 to May 2020, five patients with abdominal aortic aneurysm and severe neck angulation (≥70°) were treated with the Gore Excluder Conformable endograft at two different centers. Deployment of this endograft in this kind of anatomy should be aggressive starting over the level of renal arteries due to risk of distal migration downward on the external curvature and difficulty in upward repositioning. Authors suggested a standard technique with a routine through-and-through axillary-femoral approach, using a floppy guidewire together with preventive cannulation of the lower renal artery if a short neck (<15 mm) is associated.

RESULTS

Endovascular aortic procedures were successfully completed in all patients. Final deployment of the stent graft using our standardized technical approach was extremely precise in all cases even if redeployment of the graft was necessary in all cases. No other secondary procedures were needed. At 30 days, no type IA endoleak was recorded and no aneurysm-related secondary procedures were performed. Median follow-up for this group of patients was 5.2 months (range 1-11). Early results revealed no type IA endoleak and no migration at Ct angiogram. No aneurysm-related secondary procedures were required.

CONCLUSION

Routine use of through-and-through axillary-femoral guidewire associated with selective pre-cannulation of the lower renal artery allows a precise deployment of the Gore Excluder Conformable endograft in difficult anatomies possibly affecting early outcomes.

Endograft type and anesthesia mode are associated with mortality of endovascular aneurysm repair for ruptured abdominal aortic aneurysms

OBJECTIVE

Endovascular aneurysm repair has become the primary treatment modality for ruptured infrarenal abdominal aortic aneurysm. This study examines the impact of endograft type on perioperative outcomes for ruptured infrarenal abdominal aortic aneurysm.

METHOD

The targeted endovascular aneurysm repair files of the American College of Surgeons National Surgical Quality Improvement Program database (2012-2017) were used. Only patients treated for ruptured infrarenal abdominal aortic aneurysm were included. All patients requiring concomitant stenting of the visceral arteries or aneurysmal iliac arteries or open abdominal surgery were excluded. The characteristics of patients treated with the different endografts and the corresponding outcomes were compared using Stata software.

RESULTS

There were 479 patients treated with the three most common endografts: Cook Zenith (n = 127), Gore Excluder (n = 239), and Medtronic Endurant (n = 113). The number of other endografts was too small for statistical analysis. Compared to patients treated with Excluder or Endurant, the patients treated with Zenith had significantly lower body mass index (P < .001) and were less likely to be white (P < .001). On the other hand, patients treated with Endurant were less likely to be smoker (P = .016). Patients treated with Zenith had significantly larger ruptured infrarenal abdominal aortic aneurysm diameter (P = .045). The overall mortality was 18% and morbidity 74.3%. There was a statistically significant difference in overall mortality (Zenith = 11.8%, Excluder = 18%, Endurant = 24.8%, P = .033) but not morbidity (P = .808) between the three groups. Post hoc analysis for overall mortality showed only significant difference between Zenith and Endurant. The difference in mortality was not significant in patients presenting with ruptured infrarenal abdominal aortic aneurysm without hypotension (P = .065). On multivariable analysis, treatment with the Endurant endograft was associated with increased mortality compared to Zenith (odds ratio = 3.0 [confidence interval 1.31-6.7]). General anesthesia (odds ratio = 2.67 [confidence interval 1.02-7.02]), rupture with hypotension (odds ratio = 4.49 [confidence interval 2.54-7.95]), and dependent functional status (odds ratio = 5.7 [confidence interval 1.96-16.59]) were independently associated with increased mortality while increasing body mass index (odds ratio = 0.97 [confidence interval 0.95-0.99]) was associated with reduced risk of mortality.

CONCLUSIONS

This study highlights contemporary outcomes of endovascular aneurysm repair for ruptured infrarenal abdominal aortic aneurysm with relatively low mortality. Endograft type and anesthesia technique are modifiable factors that can potentially improve outcomes. Significant variation in the outcomes of the different endografts warrants further research.

Endovascular Aortic Repair with the "Step-by-Step" Deployment of the Endurant Stent-Graft System in Severe Neck Angulation: Technique and Review of the Literature

OBJECTIVES

To describe a new technique based on a different deployment of the Endurant Stent-Graft System (Medtronic Cardiovascular, Santa Rosa, CA) during endovascular aortic aneurysm repair to guarantee a more precise deployment in presence of severe neck angulation (SNA).

TECHNIQUE

The "step-by-step" deployment technique consists of an alternate partial release of the main body and of the free-flow suprarenal stents to approximate the radiopaque markers of the graft fabric to the aortic wall, obtaining a more precise delivery, reducing the possibility of downward dislodgments along the external curve of the infrarenal angle and asymmetrical deployments in presence of SNA.

CONCLUSIONS

The "step-by-step" technique is a simple, safe, and effective graft-deployment method, which allows a very precise release in SNA and possibly achieves better results in the long-term period in such difficult anatomies.

Endurant stent graft demonstrates promising outcomes in challenging abdominal aortic aneurysm anatomy

OBJECTIVE

We aimed to assess the 5-year safety and effectiveness outcomes of patients enrolled in the Endurant Stent Graft Natural Selection Global Post Market Registry (ENGAGE) who were treated outside the approved indications for use (IFU) of the Endurant stent graft.

METHODS

Our primary outcome measure was 12-month treatment success, defined as successful endograft delivery and deployment and the absence of type I or III endoleak, stent migration or limb occlusion, late conversion, and abdominal aortic aneurysm diameter increase or rupture. Secondary outcome measures included 30-day all-cause mortality, major adverse events, secondary procedures, technical observations, aneurysm-related mortality, and all-cause mortality within 12 months.

RESULTS

Demographic characteristics of ENGAGE patients treated outside (225 [17.8%]) and within (1038 [82.2%]) the IFUs were similar, except that female patients comprised a much higher percentage of the outside IFU group (19.1% vs 8.7%; P < .001). The outside IFU group presented with lower rates of coronary artery disease and cardiac revascularization and a greater number of symptomatic patients compared with the within IFU group (21.3% vs 15.0%; P = .020). Technical success was achieved in more than 99% of all patients. The outside and within IFU groups showed a comparable and low occurrence of uncorrected type I (0.9% vs 1.2%; P = 1.00) and type III endoleak (0.4% vs 0.3%; P = .54) immediately after device implantation. The 5-year freedom from type IA endoleaks was 89.4% vs 96.7% (P < .0001) for those patients outside and within the IFUs, respectively, although both groups had similar type III endoleaks through 5 years (P = .61). Stent graft limb occlusion estimated overall survival, and freedom from aneurysm-related mortality and endovascular interventions were comparable in both patient groups through the 5-year follow-up. The Kaplan-Meier estimates at 5 years showed a trend for low but increased need for type I or III endoleak correction procedures in the outside IFU group compared with the within IFU group (7.2% vs 5.2%; P = .099).

CONCLUSIONS

Differences were not observed in all-cause mortality, aneurysm-related mortality, and secondary procedures between within and outside IFU patients through a 5-year follow-up in the ENGAGE registry. Proximal necks with angulation or diameters outside the IFUs were the most common reasons for patients identified as being outside IFU, and the cohort had increased incidence of type IA endoleaks. Despite the challenges presented from the broad range of aortic and abdominal aortic aneurysm morphologies, the Endurant stent graft showed promising 5-year outcomes.

Three-Year Results of the Nellix Endovascular Aneurysm Sealing System for Treatment of Abdominal Aortic Aneurysms in Frail Patients with Poor Anatomical Features

Introduction:

Endovascular aneurysm sealing represents an alternative to advanced technology devices for compromised patients with abdominal aortic aneurysms. We report our results of 15 fragile patients with very low-quality infrarenal necks treated with endovascular aneurysm sealing.

Material and methods:

All patients treated with Nellix device in our hospital between June 2015 and October 2016 were retrospectively reviewed. The primary endpoints are the following: overall survival and freedom from reintervention rates. The secondary endpoints are the following: technical success; 30-day mortality; abdominal aortic aneurysm–related mortality; and freedom from endoleak rate, complications, and surgical conversion rate.

Results:

Nellix was used in 15 patients, median age 75.5 years, of which 67% were unfit for open surgery. Mean aneurysm diameter was 60 mm. One-third (5/15) of the patients were inside the Nellix instructions for use. Technical success rate was 93.3%. No perioperative complications existed, and 30-day mortality was 0%. Median follow-up was 35 (interquartile range: 11–37) months. Survival rates at 1 and 3 years were 80% and 59.3%. Abdominal aortic aneurysm–related mortality occurred in 3 of 15 cases. Freedom from rupture rates at 1 and 3 years were 92.9% and 66%. Freedom from endoleak rates at 1 and 3 years were 92.9% and 74.5%. Freedom from reintervention rates at 1 and 3 years were 86.7% and 70.6%, with a dramatic drop to 37.1% at 4 years of follow-up. Three open surgery conversions were needed. There were no statistically significant differences in results between patients treated inside and outside instructions for use.

Conclusion:

The endovascular aneurysm sealing has shown encouraging short-term results, but its safety and effectiveness during time is questionable, because this system still carries high rates of reintervention, conversions for type IA endoleaks, and secondary aneurysm ruptures.

Gender-related outcomes of chimney EVAR within the PERICLES registry

Objective

Gender-related differences in outcomes in complex endovascular aortic repair have not been profoundly investigated. Use of low profile abdominal devices as in chimney endovascular repair may be beneficial for female patients with pararenal pathologies. With the chimney technique, there is no need for large introduction sheaths. This could be an advantage in case of smaller in diameter iliac access especially in combination with stenosis or elongation. Aim of the present study was to compare the perioperative and mid-term outcomes between males and females patients treated with the chimney/snorkel technique for pararenal aortic pathologies.

Methods

The PERICLES registry collected the world wide experience with the chimney technique. According to the gender, patients were classified in two cohorts. Primary endpoints were freedom from occlusion of the chimney grafts and reintervention. Secondary endpoints included access site complications and need for surgical or interventional revision, Endoleak Type I rate, 30-day overall complications and mortality. Univariate comparison P-values were generated using either the likelihood ratio χ2 test, the Fisher exact test, the Wilcoxon rank sum test, or the log rank test. Kaplan–Meier curves estimated the outcomes in the long run.

Results

A total of 412 patients underwent Ch-EVAR, 71 (17%) females and 341 (83%) males with a mean age for both groups being 74 years were included in the present study. After 36 months of mean follow-up, no statistically significant difference was observed between the two cohorts regarding re-interventions ( P= .44). Freedom from occlusion rates at 36 months did not differed between the two groups (females 84% vs. 80% for males ( P= .033). For patients receiving more than one chimney stent, the odds of having a complication did not differ between males and females (M:F OR = 2.0, 95% CI: 0.6–6.4, P = 0.228); 30-day mortality was 0% in the female group, instead five male patients died within one month. ( P = 0.59). The incidence of acute renal failure was low in both groups without statistical difference: 2 (3.1%) vs. 13 (4.6%) 58 ( P = 1.00). Neither patient received an endoconduit to insert the abdominal device.

Conclusions

No statistically significant difference regarding the freedom from reintervention and chimney graft patency was observed between the two genders. The results highlight the beneficial use of the chimney technique in female patients who can have potentially higher risk of access complications.

Has Anatomic Complexity of Abdominal Aortic Aneurysms Undergoing Open Surgical Repair Changed after the Introduction of Endovascular Treatment? Systematic Review and Meta-analysis of Comparative Studies

BACKGROUND

At a time when endovascular aneurysm repair (EVAR) is increasingly used to treat abdominal aortic aneurysms (AAAs), lesions undergoing open surgical repair (OSR) may present significant differences compared with those treated before wide EVAR availability. We aim to record discrepancies in AAAs surgically treated before and after the introduction of EVAR.

METHODS

We conducted a systematic review of the literature and meta-analysis of comparative studies. The MEDLINE, CENTRAL, and OpenGrey databases were searched up to October 2017. Outcome measures were anatomic complexity, procedural details, and postoperative outcomes. The random-effects model was used to calculate combined overall effect sizes. Data are presented as odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CIs).

RESULTS

Five observational studies were included. These involved 1,091 patients treated in the pre-EVAR era and 802 in the post-EVAR era. In general, patients undergoing OSR during the first period presented more comorbidities. Increased anatomic complexity was found among patients in the second group as demonstrated by the increased rate of suprarenal clamping (10.5% vs. 22.3%; OR, 0.34; 95% CI, 0.24-0.50), left renal vein division (10.3% vs. 18.8%; OR, 0.46; 95% CI, 0.25-0.88), iliac aneurysm (28.3% vs. 44.9%; OR, 0.48; 95% CI, 0.37-0.64), and iliac occlusive disease (13.1% vs. 20.2%; OR, 0.59; 95% CI, 0.39-0.88). Intraoperative use of blood products was greater during the latter period, but this difference did not reach statistical significance. Procedural duration was slightly increased in the same group. Morbidity and mortality were similar among the groups.

CONCLUSIONS

After the wide availability of endoluminal grafting, more compromised patients tend to be managed with EVAR, leaving a fitter patient population to undergo OSR. At the same time, anatomic complexity of AAAs undergoing open surgery has considerably increased, requiring advanced proximal aortic surgical expertise to deal with these complex aortic pathologies Overall, morbidity and mortality remained unchanged, possibly due to the counterbalancing effects of these factors.

Two-Year Outcomes of the Nellix EndoVascular Aneurysm Sealing System for Treatment of Abdominal Aortic Aneurysms

Purpose: To analyze the 2-year outcomes of endovascular aneurysm sealing (EVAS) according to 2 versions of the instructions for use (IFU). Methods: A retrospective study was conducted involving 355 consecutive patients treated with the first-generation EVAS device from April 2013 to December 31, 2015, at 3 high-volume centers. Out of 355 patients treated with EVAS, 264 were elective asymptomatic infrarenal EVAS procedures suitable for analysis. In this cohort, 168 (63.3%) patients were treated within the IFU 2013 criteria; of these 48 (18.2%) were in compliance with the revised IFU 2016 version. Results: Overall technical success was 98.2% (165/168) in the IFU 2013 group and 97.9% (47/48) in the IFU 2016 subgroup (p=0.428). The 2-year freedom from reintervention estimates were 89.7% (IFU 2013) and 95.7% (IFU 2016), with significantly more reinterventions in the first 45 cases (p=0.005). The stenosis/occlusion estimates were 6.5% (IFU 2013) and 4.2% (IFU 2016; p=0.705). Nine (5.4%) endoleaks (8 type Ia and 1 type Ib) were observed within the IFU 2013 cohort; 3 (2.1%) were in the IFU 2016 subgroup (p=0.583). Migration ≥10 mm or ≥5 mm requiring intervention was reported in 12 (7.1%) patients in the IFU 2013 cohort but none within the IFU 2016 subgroup. Ten (6.0%) patients demonstrated aneurysm growth in the IFU 2013 cohort, of which 2 (4.2%) were in the IFU 2016 subgroup. Overall survival and freedom from aneurysm-related death estimates at 2 years were 90.9% and 97.6% in the IFU 2013 cohort (IFU 2016: 95.5% and 100.0%). The prevalence of complications seemed lower within IFU 2016 without significant differences. Conclusion: This study shows acceptable 2-year results of EVAS used within the IFU, without significant differences between the 2 IFU versions, though longer follow-up is indicated. The refined IFU significantly reduced the applicability of the technique.

A Semiautomated Method for Measuring the 3-Dimensional Fabric to Renal Artery Distances to Determine Endograft Position After Endovascular Aneurysm Repair

Purpose: To report a methodology for 3-dimensional (3D) assessment of the stent-graft deployment accuracy after endovascular aneurysm repair (EVAR). Methods: A methodology was developed and validated to calculate the 3D distances between the endograft fabric and the renal arteries over the curve of the aorta. The shortest distance between one of the renal arteries and the fabric (SFD) and the distance from the contralateral renal artery to the fabric (CFD) were determined on the first postoperative computed tomography (CT) scan of 81 elective EVAR patients. The SFDs were subdivided into a target position (0–3 mm distal to the renal artery), high position (partially covering the renal artery), and low position (>3 mm distal to the renal artery). Data are reported as the median (interquartile range, IQR). Results: Intra- and interobserver agreements for automatic and manual calculation of the SFD and CFD were excellent (ICC >0.892, p<0.001). The median SFD was 1.4 mm (IQR −0.9, 3.0) and the median CFD was 8.0 mm (IQR 3.9, 14.2). The target position was achieved in 44%, high position in 30%, and low position in 26% of the patients. The median slope of the endograft toward the higher renal artery was 2.5° (IQR −5.5°, 13.9°). Conclusion: The novel methodology using 3D CT reconstructions enables accurate evaluation of endograft position and slope within the proximal aortic neck. In this series, only 44% of endografts were placed within the target position with regard to the lowermost renal artery.

A Systematic Review of Predictors of Reintervention After EVAR: Guidance for Risk-Stratified Surveillance

BACKGROUND

Current surveillance protocols after endovascular aneurysm repair (EVAR) are ineffective and costly. Stratifying surveillance by individual risk of reintervention requires an understanding of the factors involved in developing post-EVAR complications. This systematic review assessed risk factors for reintervention after EVAR and proposals for stratified surveillance.

METHODS

A systematic search according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed using EMBASE and MEDLINE databases to identify studies reporting on risk factors predicting reintervention after EVAR and proposals for stratified surveillance.

RESULTS

Twenty-nine studies reporting on 39 898 patients met the primary inclusion criteria for reporting predictors of reintervention or aortic complications with or without suggestions for stratified surveillance. Five secondary studies described external validation of risk scores for reintervention or aortic complications. There was great heterogeneity in reporting risk factors identified at the pre-EVAR, intraoperative, and post-EVAR stages of treatment, although large preoperative abdominal aortic aneurysm diameter was the most commonly observed risk factor for reintervention after EVAR.

CONCLUSION

Existing data on predictors of post-EVAR complications are generally of poor quality and largely derived from retrospective studies. Few studies describing suggestions for stratified surveillance have been subjected to external validation. There is a need to refine risk prediction for EVAR failure and to conduct prospective comparative studies of personalized surveillance with standard practice.

Preliminary experience with the Endurant II short form stent-graft system

BACKGROUND

The aim of this study was to evaluate our preliminary experience with the use of the Endurant II short form (IIs) stent-graft in the treatment of abdominal aortic aneurysms (AAAs).

METHODS

Between November 2014 and November 2015, 79 patients were consecutively treated with the Endurant IIs stent-graft at three European vascular centers. Early (30-day) results in terms of technical success, limb occlusion, major morbidity, and mortality were analyzed. Estimated 1-year outcomes in terms of survival, freedom from type I endoleak, freedom from limb occlusion, and freedom from any device-related reinterventions were assessed with Kaplan-Meyer method. Factors affecting 1-year freedom from type I endoleak were analyzed by log-rank test and by Cox regression test for multivariate analysis.

RESULTS

Intraoperative technical success was achieved in all cases. Thirty-day mortality was 1.3% (one death due to cardiac failure). Early type I endoleak was detected in three patients (3.8%). During the follow-up (mean duration 6.7 months; range 1-14), two type I endoleaks resolved spontaneously. No limb occlusions or aneurysm-related reinterventions were recorded. Estimated survival, freedom from type I endoleak, freedom from limb occlusions, and freedom from any device-related reinterventions rates at 1 year were 96%, 96.6%, 100%, and 100%, respectively. Adoption of chimney technique significantly affected 1-year freedom from type I endoleak (P≤0.001).

CONCLUSIONS

Preliminary use of the new Endurant IIs stent-graft is safe and effective in endovascular repair of AAAs (EVAR) without early limb occlusions. Further studies with larger population sizes and longer follow-up are needed to evaluate mid- and long-term results.

A clinical and ethical review on late results and benefits after EVAR

Introduction

The aim of this review is to assess if late mortality after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) is a real problem, and whether it could be an issue in the case of medical litigation.

Material and methods

A review of all English language literature was performed on PubMed web-site, looking for all papers reporting EVAR long-term mortality rate. EVAR performances were reviewed also from an ethical and medico-legal point of view, based on current Italian laws.

Results

Mono-centric studies, and international registers suggest that today EVAR offers similar (if not better) results than open repair (OR) in the treatment of AAAs with standard and complex anatomies, even if performed outside the devices-specific instructions for use. In contrast, large randomized trials, and consequently current guidelines, suggest that EVAR still has an ancillary role compared to OR, only to be used for highly selected patients.

Recently, specific litigation cases on surgical options related to the treatment of aortic aneurysms has developed. The informed consent process needs to include not only mortality and major complications related to the procedure but also the chance of patients' outcomes. For those reasons, the generic nature of informed consent has been criticized.

Conclusions

No conclusive data is currently available to assess the initial question of late mortality after EVAR but results are still improving. In the meantime, widespread use of EVAR as first choice for treating AAA may only be acceptable in high-volume centres validating their results by a strict follow up protocol.

•

The long-term results after endovascular repair (EVAR) for abdominal aortic aneurysms (AAA) are still considered one of the main limitations of this treatment option.

•

This paper is a comprehensive review of the current literature on long-term mortality after EVAR procedures.

•

An analysis on informed consent for EVAR from a non-surgical point of view is reported for the very first time.

Push-Up Technique and Anatomical Deployment With the Endurant Stent-Graft System for Severely Angulated Aneurysm Necks

PURPOSE

To describe a technique suitable for treating severely angulated (>75°) necks during endovascular aneurysm repair using the Endurant stent-graft.

TECHNIQUE

In the push-up technique, the suprarenal stent is released early to fix the proximal stent-graft in place so that each stent in the neck can be deployed individually without displacing the device upward. It is important to push the delivery system up after each stent deployment to allow the fabric between the stents to fold up circumferentially. By doing so, there is minimal upward force applied to the suprarenal stent. Because the stents expand along the angulated neck while catching blood flow, this anatomical deployment is feasible, with hardly any change to the proximal neck shape after stent-graft implantation.

CONCLUSION

The push-up technique and anatomical deployment with the Endurant stent-graft system are effective and safe methods for treating aneurysms with severely angulated necks.

Abdominal Aortic Aneurysm Repair: Results from a Series of Young Patients

Objectives. To compare durability and survival after endovascular aneurysm repair (EVAR) and open repair (OR) of abdominal aortic aneurysms (AAAs) in young patients. Material and Methods. A retrospective study was conducted between 2005 and 2014 on all consecutive patients of 60 years of age or younger. Measures considered for analysis were reintervention related to AAA, laparotomy and access vessel injury during EVAR, and all-cause mortality during hospitalization and follow-up. Results. Seventy out of 119 patients were treated by OR (58.8%) and 49 (41.2%) by EVAR, 9 in off-label fashion (18.3%). Technical success was achieved in all cases. No AAA-related death was recorded. Overall in-hospital mortality was zero and the reintervention rate was 2.5% (3/119: 1/70 OR, 2/49 EVAR, p = 0.36). There is no death at 30-day or 1-year follow-up. Thirty-day reintervention rate was 1.6% (2/119; 0/70 OR, 2/49 EVAR, p = 0.16), while the 1-year rate was 2.5% (3/119; 1/70 OR, 2/49 EVAR, p = 0.36). At the mean follow-up of 56.8 ± 42.7 months, mortality and reintervention rates were 5.8% (7/119; 3/70 OR, 4/49 EVAR, p = 0.38) and 10% (12/119; 8/70 OR, 4/49 EVAR, p = 0.39), respectively. The overall reintervention rate, mortality, and freedom from adverse events did not differ between the two groups. No differences in outcome were recorded between patients treated by EVAR in on-label versus off-label fashion. Conclusion. Our (albeit limited) experience suggests that, in an unselected young patient population undergoing elective AAA repair, OR or EVAR can be performed safely with similar immediate and long term outcomes.

One Year Outcome Using Newer Generation Endografts: A National Multicenter Study on Real Word Practice

BACKGROUND

The aim of this study was to assess the 1 year outcomes following endovascular aortic aneurysm repair (EVAR) with the use of newer generation endografts.

METHODS

Retrospective analysis was conducted of prospectively collected multicenter data from 385 EVARs. Newer endografts were defined as those introduced after 2004. Patients' demographics and comorbidities, type of operation, and abdominal aortic aneurysm (AAA) morphological characteristics were analyzed. Computer tomography was performed 1 month and 1 year post-EVAR.

RESULTS

Mean age of the patients was 71.3 years; in 335 cases the intervention was elective. The mean AAA sac, neck diameter, and length were 57.15, 24.5, and 28.97 mm, respectively. Ninety-four endoleaks were recorded in 92 patients (25%), including 11 type 1a (T1aE), 3 type 1b, and 78 type 2 (T2E) endoleaks. On logistic regression analysis, neck diameter >30 mm (P = 0.032) and initial AAA sac diameter >55 mm (P = 0.031) were associated with T1aE. No association was found with T2E. Overall, 107 (27%) patients had sac expansion at 1 year associated with the presence of T2E (P = 0.019). No association was observed between T1aE or T2E and specific endograft.

CONCLUSIONS

Newer generation endografts show very satisfactory performance even in difficult anatomies. T1aE was associated with initial sac and neck diameter, while AAA sac expansion was associated with the presence of T2E.

Fenestrated stent grafts for the treatment of complex aortic aneurysm disease: A mature treatment paradigm

The introduction of fenestrated stent grafts (SGs) to treat abdominal aortic aneurysms (AAAs) with short proximal necks began in 1999. Nowadays, the whole visceral aorta can be treated totally by endovascular means. The established use of fenestrated devices to treat complex AAAs as a first-line management option has been previously reported. An up-to-date evaluation of the literature was performed including all types of publications regarding the use of fenestrated technology to repair complex AAAs. Fenestrated repair is now an established alternative to hybrid/chimney/snorkel repairs. However, specific criteria and prerequisites are required for the use and improvement of this method. Multiple device morphologies have been used incorporating the visceral arteries in various combinations. This modular strategy connects different devices (bridging covered stents and bifurcated SGs) with the aortic main body, thus excluding the aneurysm from the circulation. Precise deployment of the fenestrated SG is mandatory for successful visceral vessel revascularization. Accurate SG sizing and customization, a high level of technical skill, and facilities with modern imaging techniques including 3D road mapping and dedicated hybrid rooms are required. Most experience has been with the custom-made Zenith Cook platform, although off-the-shelf devices have been recently implanted. More complex repairs have been performed over the last few years, but device complexity has also increased. Perioperative, mid-term, and a few recently reported long-term results are encouraging. Secondary interventions remain the main problem, similar to that observed after traditional endovascular abdominal aortic aneurysm repair (EVAR).

Current aortic endografts for the treatment of abdominal aortic aneurysms

Endovascular Aneurysm Repair is a widely adopted method of treatment for patients with abdominal aortic aneurysms. The minimally invasive approach offered with EVAR has become popular not only among physicians and patients, but in the medical device industry as well. Over the past 25 years the global market for aortic endografts has increased rapidly, resulting in a wide range of devices from various companies. Currently, there are seven endografts approved by the FDA for the treatment of abdominal aortic aneurysms. These devices offer a wide range of designs intended to increase inclusion criteria while decreasing technical complications such as endoleak and migration. Despite advances in device design, secondary interventions and follow-up requirements remain a significant issue. New devices are currently being studied in the U.S. and abroad and may significantly reduce complications and secondary interventions.

Late single-center outcome of the Talent Abdominal Stent Graft after a decade of follow-up

OBJECTIVE

Lifelong yearly surveillance is advised after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms. This follow-up requires a substantial amount of health care resources. The aim of this paper was to assess the occurrence of stent graft-related complications and secondary interventions during a minimum 10-year follow-up after elective EVAR.

METHODS

Patients who were treated in a high-volume endovascular center in The Netherlands with the Talent infrarenal stent graft (Medtronic Vascular, Santa Rosa, Calif) between June 1999 and February 2005 were included. Patients with previous aortic surgery or emergency interventions were excluded. Our primary outcome was clinical success up to 10 years. Secondary end points were technical success and survival.

RESULTS

A total of 149 patients were included; 91.9% were male. The mean age was 70.2 ± 7.8 years. A stent graft was implanted in 98% of patients; technical success was achieved in 89.9%. Clinical success after 30 days, 1 year, 5 years, and 10 years was 81.1%, 74.3%, 70.3%, and 65.5%, respectively. In 30 patients (20.7%), a secondary intervention was required; 80.0% of first secondary interventions occurred within the first 5 years. Six late conversions were necessary because of stent graft infection (2), migration (2), or persisting endoleak (2). The 5- and 10-year overall survival rates were 55.2% and 38.6%, respectively.

CONCLUSIONS

The risk of EVAR-related complication is highest in the first 5 years. Consequently, the main focus should be on that period; further follow-up must not be neglected, as complications occur up to 10 years after treatment.

Outcomes of Endurant stent graft in narrow aortic bifurcation

OBJECTIVE

The purpose of this study was to compare the outcomes obtained with Endurant stent graft in the early and midterm period in the treatment of patients with narrow aortic bifurcation vs patients with standard aortic bifurcation.

METHODS

Data were prospectively collected from 817 patients with abdominal aortic aneurysm treated between November 2007 and August 2014 with the Endurant stent graft at our center. There were 87 patients (10.6%) with a narrow aortic bifurcation (≤20 mm; NA group). The remaining 730 patients (89.4%) had a standard aortic bifurcation (SA group). Early and estimated 3-year outcomes were evaluated in these patients in terms of survival, freedom from any device-related reinterventions, and freedom from graft thrombosis. Univariate and multivariate analyses in the NA group were performed to detect possible predictors for poor outcomes.

RESULTS

The two groups were similar in terms of demographics, preoperative diagnostic assessment, and intraoperative data. In 211 of 817 patients (25.8%), an adjunctive iliac limb stenting by balloon-expanding stents was performed. Overall, 41 patients in the NA group (47.1%) underwent iliac limb stenting, whereas an iliac stent was implanted in just 170 patients (23.3%) in the SA group (P < .001). The mean follow-up was 16.3 months (range, 1-73 months). The estimated 3-year survival rate was similar between the two groups (87.2% in the NA group vs 80.8% in the SA group; P = .84). Furthermore, the estimated freedom from any device-related reinterventions was 92.9% in the NA group and 85.5% in the SA group (P = .1). Finally, the estimated 3-year freedom from graft thrombosis was 96.9% in the NA group and 94.8% in the SA group (P = .79). In the NA group at univariate and multivariate analyses, none of the examined preoperative or intraoperative factors were independent predictors of poor outcomes.

CONCLUSIONS

Use of bifurcated Endurant stent graft, combined in almost half of the patients with narrow aortic bifurcation with additional aortoiliac stent placement, is feasible and safe. Early and midterm outcomes are similar to those obtained in non-narrow aortic bifurcation.