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Penton A, Li R, Carmon L, Soult MC, Bechara CF, Blecha M. Preoperative risk score for mortality within 3 years of visceral segment fenestrated endovascular aortic repair. J Vasc Surg 2024; 80:32-44.e4. [PMID: 38479540 DOI: 10.1016/j.jvs.2024.03.012] [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: 01/25/2024] [Revised: 02/19/2024] [Accepted: 03/04/2024] [Indexed: 04/08/2024]
Abstract
OBJECTIVE The purpose of this study was to create a risk score for the event of mortality within 3 years of complex fenestrated visceral segment endovascular aortic repair utilizing variables existing at the time of preoperative presentation. METHODS After exclusions, 1916 patients were identified in the Vascular Quality Initiative who were included in the analysis. The first step in development of the risk score was univariable analysis for the primary outcome of mortality within 3 years of surgery. χ2 analysis was performed for categorical variables, and comparison of means with independent Student t-test was performed for ordinal variables. Variables that achieved a univariable P value less than 0.1 were then placed into Cox regression multivariable time dependent analysis for the development of mortality within 3 years. Variables that achieved a multivariable significance of less than 0.1 were utilized for the risk score, with point weighting based on the beta-coefficient. Variables with a beta coefficient of 0.25 to 0.49 were assigned 1 point, 0.5 to 0.74 2 points, 0.75 to 0.99 3 points, and 1.0 to 1.25 4 points. A cumulative score for each patient was then summed, the percentage of patients at each score experiencing mortality within 3 weeks was then calculated, and a comparison of score outcomes was conducted with binary logistic regression. Area under the curve analysis was performed. RESULTS The primary outcome of mortality within 3 years of surgery occurred in 12.8% of patients (245/1916). The mean age for the study population was 73.35 years (standard deviation [SD], 8.26 years). The mean maximal abdominal aortic aneurysm (AAA) diameter was 60.43 mm (SD, 10.52 mm). The mean number of visceral vessels stented was 3.3 (SD, 0.76). Variables present at the time of surgery that were included in the risk score were: hemodialysis (3 points); age >87, chronic obstructive pulmonary disease, hypertension, AAA diameter >77 mm (all 2 points); and body mass index <20 kg/m2, female sex, congestive heart failure, active smoking, chronic renal insufficiency, age 80 to 87 years, and AAA diameter 67 to 77 mm (all 1 point). BMI >30 kg/m2 (mean, 34.46 kg/m2) and age <67 years were protective (-1 point). Testing the model resulted in an area under the curve of 0.706. Hosmer and Lemeshow goodness of fit test for logistic regression utilizing the 15 different risk score total groups revealed a model predictive accuracy of 87.3%. Significant escalations in 3-year mortality were noted to occur at scores of 6 and greater. Mean AAA diameter was significantly larger for patients who had higher risk scores (P < .001). CONCLUSIONS A novel risk score for mortality within 3 years of fenestrated visceral segment aortic endograft has been developed that has excellent accuracy in predicting which patients will survive and derive the strongest benefit from intervention. This facilitates risk-benefit analysis and counseling of patients and families with realistic long-term expectations. This potentially enhances patient-centered decision-making.
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Affiliation(s)
- Ashley Penton
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Maywood, IL
| | - Ruojia Li
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Maywood, IL
| | - Lauren Carmon
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Maywood, IL
| | - Michael C Soult
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Maywood, IL
| | - Carlos F Bechara
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Maywood, IL; Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Maywood, IL; Stritch School of Medicine, Loyola University Chicago, Maywood, IL.
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Martinelli O, Cuozzo S, Miceli F, Gattuso R, D'Andrea V, Sapienza P, Bellini MI. Elective Endovascular Aneurysm Repair (EVAR) for the Treatment of Infrarenal Abdominal Aortic Aneurysms of 5.0-5.5 cm: Differences between Men and Women. J Clin Med 2023; 12:4364. [PMID: 37445398 DOI: 10.3390/jcm12134364] [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: 05/24/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND There is significant debate regarding the existence of sex-related differences in the presentation, treatment, and outcomes of men versus women affected by abdominal aortic aneurysm (AAA). The purpose of this study is to compare endovascular aneurysm repair (EVAR) of infrarenal AAAs with the current sex-neutral 5.0-5.5 cm-diameter threshold for intervention between the two sexes. METHODS Retrospective review of consecutive cases from a single teaching institution over a period of five years of patients who had undergone elective EVAR for AAAs between 5.0 and 5.5 cm in diameter. Outcomes of interest were compared according to sex. RESULTS Ninety-four patients were included in the analysis, with a higher prevalence of men (53%). Females were older at the time of repair, 78 ± 5.1 years, versus 71.7 ± 7 years (p < 0.01), and had higher incidence of underlying comorbidities, namely, arrhythmia, chronic kidney disease, and previous carotid revascularization. Women had higher incidence of immediate systemic complications (p = 0.021), post-operative AMI (p = 0.001), arrhythmia (p = 0.006), pulmonary oedema (p < 0.001), and persistent renal dysfunction (p = 0.029). Multivariate analysis for post-operative factors associated to mortality and adjusted for sex confirmed that AMI (p = 0.015), arrhythmia (p = 0.049), pulmonary oedema (p = 0.015), persistent renal dysfunction (p < 0.001), cerebral ischemia (p < 0.001), arterial embolism of lower limbs (p < 0.001), and deep-vein thrombosis of lower limbs (p < 0.001) were associated to higher EVAR-related mortality; a higher incidence of post-operative AMI (p = 0.014), pulmonary edema (p = 0.034), and arterial embolism of lower limbs (p = 0.046) were associated to higher 30-days mortality. In females there was also a higher rate of suprarenal fixation (p = 0.026), insertion outside the instruction for use (p = 0.035), and a more hostile neck anatomy with different proximal aortic diameter (p < 0.001) and angle (p = 0.003). CONCLUSIONS A similar threshold of size of AAA for elective surgery for both males and females might not be appropriate for surgical intervention, as females tend to have worse outcomes. Further population-based studies are needed to guide on sex-related differences and intervention on AAA.
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Affiliation(s)
- Ombretta Martinelli
- Department of General and Speciality Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Simone Cuozzo
- Department of General and Speciality Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Francesca Miceli
- Department of General and Speciality Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Roberto Gattuso
- Department of General and Speciality Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Vito D'Andrea
- Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Paolo Sapienza
- Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy
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Tomee SM, Bulder RMA, Meijer CA, van Berkum I, Hinnen JW, Schoones JW, Golledge J, Bastiaannet E, Matsumura JS, Hamming JF, Hultgren R, Lindeman JH. Excess Mortality for Abdominal Aortic Aneurysms and the Potential of Strict Implementation of Cardiovascular Risk Management: A Multifaceted Study Integrating Meta-Analysis, National Registry, and PHAST and TEDY Trial Data. Eur J Vasc Endovasc Surg 2023; 65:348-357. [PMID: 36460276 DOI: 10.1016/j.ejvs.2022.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 11/02/2022] [Accepted: 11/23/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Previous studies imply a profound residual mortality risk following successful abdominal aorta aneurysm (AAA) repair. This excess mortality is generally attributed to increased cardiovascular risk. The aim of this study was (1) to quantify the excess residual mortality for patients with AAA, (2) to evaluate the cross sectional level of cardiovascular risk management, and (3) to estimate the potential of optimised cardiovascular risk management to reduce the excess mortality in these patients. METHODS Excess mortality was estimated through a systematic review and meta-analysis, and through data from the Swedish National Health Registry. Cardiovascular risk profiles were individually assessed during eligibility screening of patients with AAA for two multicentre pharmaceutical AAA stabilisation trials. The potential of full implementation of cardiovascular risk management was estimated through the validated Second Manifestations of ARTerial disease (SMART) risk scores algorithm. RESULTS The meta-analysis showed a similarly impaired survival for patients who received early repair (small AAA) or regular repair (≥ 55 mm), and a further impaired survival for patients under surveillance for a small AAA. Excess mortality was further quantified using Swedish population data. The data revealed a more than quadrupled and doubled five year mortality rate for women and men who had their AAA repaired, respectively. Evaluation of the level of risk management of 358 patients under surveillance in 16 Dutch hospitals showed that the majority of patients with AAA did not meet therapeutic targets set for risk management in high risk populations, and indicated a more pronounced prevention gap in women. Application of the SMART risk score algorithm predicted that optimal implementation of risk management guidelines would reduce the 10 year risk of major adverse cardiovascular events from 43% to 14%. CONCLUSION Independent of the rupture risk, AAA is associated with a worryingly compromised life expectancy with a particularly poor prognosis for women. Optimal implementation of cardiovascular risk prevention guidelines is predicted to profoundly reduce cardiovascular risk.
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Affiliation(s)
- Stephanie M Tomee
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Ruth M A Bulder
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - C Arnoud Meijer
- Department of Radiology, Martini Hospital, Groningen, the Netherlands
| | - Ingrid van Berkum
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jan-Willem Hinnen
- Department of Vascular Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, GZ, the Netherlands
| | - Jan W Schoones
- Walaeus Library, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jonathan Golledge
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Australia; Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Australia
| | - Esther Bastiaannet
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jon S Matsumura
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jaap F Hamming
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Rebecka Hultgren
- Department of Vascular Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Jan H Lindeman
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands.
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Fan EY, Buckner MA, LiCausi J, Crawford A, Boitano LT, Malka KT, Schanzer A, Simons JP. Characterizing the frequency and indications for repair of abdominal aortic aneurysms with diameters smaller than recommended by societal guidelines. J Vasc Surg 2023; 77:1637-1648.e3. [PMID: 36773667 DOI: 10.1016/j.jvs.2023.01.201] [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: 10/31/2022] [Revised: 01/17/2023] [Accepted: 01/23/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE While the Society for Vascular Surgery recommends repair of abdominal aortic aneurysms (AAA) at ≥5.5 cm in men and ≥5.0 cm in women, AAA repair below these thresholds has been well documented. There are clear indications for repair other than these strict size criteria, but the expected proportion of such repairs in one's practice has not been studied. We sought to characterize the indications for repairs of aneurysms below diameter recommendations at a single academic center. Using the assumption that this real-world experience would approximate that of other practices, we then used national data to extrapolate these findings. METHODS A single-center retrospective review was conducted of all elective open (oAAA) and endovascular (EVAR) AAA repairs (2010-20) to assess the incidence of and indications for repair of aneurysms below diameter recommendations (defined as <5.5cm in men and <5.0cm in women). Reasons for these repairs were defined as: 1) iliac aneurysm, 2) saccular morphology, 3) rapid expansion, 4) patient anxiety, 5) distal embolization, 6) other, and 7) no documented reason. The Vascular Quality Initiative (VQI) was queried for all asymptomatic oAAA and EVAR (2010-20) and repairs below diameter recommendations were identified. Findings from the single-center analysis were applied to the VQI cohort to extrapolate estimates of reasons for repairs done nationally. In-hospital mortality and major adverse cardiac events (MACE) were compared between those below size recommendations and those meeting size recommendations. RESULTS Of 456 elective AAA repairs at our center, 147 (32%) were below size recommendations. This was more common for EVAR (35% vs 28%). Reasons were: not documented (41%), iliac aneurysm (23%), saccular (10%), rapid expansion (10%), patient anxiety (7%), other (6%), and distal embolism (3%). Of 44,820 elective AAA repairs in VQI, 17,057 (38%) were below size recommendations (40% EVAR, 26% oAAA). Patients who were repaired below size recommendations had lower in-hospital death (oAAA: 2.4% vs 4.6% p<0.0001; EVAR: 0.3% vs 0.8% p<0.0001). When single-center findings were applied to the VQI dataset, an estimated 10,064 repairs were performed nationally for acceptable indications other than size criteria. Conversely, there may have been 6993 repairs (with an associated 35 deaths) performed without documented indication. CONCLUSION Repairs for AAA below recommended diameter guidelines account for approximately one third of all elective AAA procedures in both VQI and our single-center experience. Assuming our practice is typical, nearly 60% of repairs below size recommendations meet criteria for other clear reasons. The remaining 40% lack a documented reason, meaning 13% of all elective AAA repairs were done for aneurysms below size recommendations without an acceptable indication. As awareness of overuse/underuse is heightened, these data help estimate the expected proportion of repairs for less common pathologies. They also provide a potential baseline data point for efforts at reducing overuse.
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Affiliation(s)
- Emily Y Fan
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | | | - Joseph LiCausi
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Allison Crawford
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Kimberly T Malka
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, ME
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Jessica P Simons
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA.
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Vedani SM, Petitprez S, Weinz E, Corpataux JM, Déglise S, Deslarzes-Dubuis C, Côté E, Ricco JB, Saucy F. Predictors and Consequences of Sac Shrinkage after Endovascular Infrarenal Aortic Aneurysm Repair. J Clin Med 2022; 11:jcm11113232. [PMID: 35683617 PMCID: PMC9181709 DOI: 10.3390/jcm11113232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/28/2022] [Accepted: 06/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Aneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). We evaluated the impact of sac shrinkage on secondary interventions, on survival and its association with endoleaks, and on compliance with instructions for use (IFU). Methods: This observational retrospective study was conducted on all consecutive patients receiving EVAR for an infrarenal abdominal aortic aneurysm (AAA) using exclusively Endurant II/IIs endograft from 2014 to 2018. Sixty patients were entered in the study. Aneurysm sac shrinkage was defined as decrease ≥5 mm of the maximum aortic diameter. Univariate methods and Kaplan–Meier plots assessed the potential impact of shrinkage. Results: Twenty-six patients (43.3%) experienced shrinkage at one year, and thirty-four (56.7%) had no shrinkage. Shrinkage was not significantly associated with any demographics or morbidity, except hypertension (p = 0.01). No aneurysm characteristics were associated with shrinkage. Non-compliance with instructions for use (IFU) in 13 patients (21.6%) was not associated with shrinkage. Three years after EVAR, freedom from secondary intervention was 85 ± 2% for the entire series, 92.3 ± 5.0% for the shrinkage group and 83.3 ± 9% for the no-shrinkage group (Logrank: p = 0.49). Survival at 3 years was not significantly different between the two groups (85.9 ± 7.0% vs. 79.0 ± 9.0%, Logrank; p = 0.59). Strict compliance with IFU was associated with less reinterventions at 3 years (92.1 ± 5.9% vs. 73.8 ± 15%, Logrank: p = 0.03). Similarly, survival at 3 years did not significantly differ between strict compliance with IFU and non-compliance (81.8 ± 7.0% vs. 78.6 ± 13.0%, Logrank; p = 0.32). Conclusion: This study suggests that shrinkage ≥5 mm at 1-year is not significantly associated with a better survival rate or a lower risk of secondary intervention than no-shrinkage. In this series, the risk of secondary intervention regardless of shrinkage seems to be linked more to non-compliance with IFU. Considering the small number of patients, these results must be confirmed by extensive prospective studies.
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Affiliation(s)
- Sébastien Michel Vedani
- Department of Vascular Surgery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland; (S.M.V.); (S.P.); (E.W.); (J.-M.C.); (S.D.); (C.D.-D.); (E.C.)
| | - Séverine Petitprez
- Department of Vascular Surgery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland; (S.M.V.); (S.P.); (E.W.); (J.-M.C.); (S.D.); (C.D.-D.); (E.C.)
| | - Eva Weinz
- Department of Vascular Surgery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland; (S.M.V.); (S.P.); (E.W.); (J.-M.C.); (S.D.); (C.D.-D.); (E.C.)
| | - Jean-Marc Corpataux
- Department of Vascular Surgery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland; (S.M.V.); (S.P.); (E.W.); (J.-M.C.); (S.D.); (C.D.-D.); (E.C.)
| | - Sébastien Déglise
- Department of Vascular Surgery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland; (S.M.V.); (S.P.); (E.W.); (J.-M.C.); (S.D.); (C.D.-D.); (E.C.)
| | - Céline Deslarzes-Dubuis
- Department of Vascular Surgery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland; (S.M.V.); (S.P.); (E.W.); (J.-M.C.); (S.D.); (C.D.-D.); (E.C.)
| | - Elisabeth Côté
- Department of Vascular Surgery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland; (S.M.V.); (S.P.); (E.W.); (J.-M.C.); (S.D.); (C.D.-D.); (E.C.)
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, 86073 Poitiers, France;
| | - François Saucy
- Department of Vascular Surgery, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland; (S.M.V.); (S.P.); (E.W.); (J.-M.C.); (S.D.); (C.D.-D.); (E.C.)
- Service of Vascular Surgery, Ensemble Hospitalier de la Côte, 1110 Morges, Switzerland
- Correspondence:
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Decker JA, Bette S, Scheurig-Muenkler C, Jehs B, Risch F, Woźnicki P, Braun FM, Haerting M, Wollny C, Kroencke TJ, Schwarz F. Virtual Non-Contrast Reconstructions of Photon-Counting Detector CT Angiography Datasets as Substitutes for True Non-Contrast Acquisitions in Patients after EVAR-Performance of a Novel Calcium-Preserving Reconstruction Algorithm. Diagnostics (Basel) 2022; 12:558. [PMID: 35328111 PMCID: PMC8946873 DOI: 10.3390/diagnostics12030558] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/17/2022] [Accepted: 02/19/2022] [Indexed: 02/01/2023] Open
Abstract
The purpose of this study was to evaluate virtual-non contrast reconstructions of Photon-Counting Detector (PCD) CT-angiography datasets using a novel calcium-preserving algorithm (VNCPC) vs. the standard algorithm (VNCConv) for their potential to replace unenhanced acquisitions (TNC) in patients after endovascular aneurysm repair (EVAR). 20 EVAR patients who had undergone CTA (unenhanced and arterial phase) on a novel PCD-CT were included. VNCConv- and VNCPC-series were derived from CTA-datasets and intraluminal signal and noise compared. Three readers evaluated image quality, contrast removal, and removal of calcifications/stent parts and assessed all VNC-series for their suitability to replace TNC-series. Image noise was higher in VNC- than in TNC-series (18.6 ± 5.3 HU, 16.7 ± 7.1 HU, and 14.9 ± 7.1 HU for VNCConv-, VNCPC-, and TNC-series, p = 0.006). Subjective image quality was substantially higher in VNCPC- than VNCConv-series (4.2 ± 0.9 vs. 2.5 ± 0.6; p < 0.001). Aortic contrast removal was complete in all VNC-series. Unlike in VNCConv-reconstructions, only minuscule parts of stents or calcifications were erroneously subtracted in VNCPC-reconstructions. Readers considered 95% of VNCPC-series fully or mostly suited to replace TNC-series; for VNCConv-reconstructions, however, only 75% were considered mostly (and none fully) suited for TNC-replacement. VNCPC-reconstructions of PCD-CT-angiography datasets have excellent image quality with complete contrast removal and only minimal erroneous subtractions of stent parts/calcifications. They could replace TNC-series in almost all cases.
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Affiliation(s)
- Josua A. Decker
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (J.A.D.); (S.B.); (C.S.-M.); (B.J.); (F.R.); (P.W.); (F.M.B.); (M.H.); (C.W.); (F.S.)
| | - Stefanie Bette
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (J.A.D.); (S.B.); (C.S.-M.); (B.J.); (F.R.); (P.W.); (F.M.B.); (M.H.); (C.W.); (F.S.)
| | - Christian Scheurig-Muenkler
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (J.A.D.); (S.B.); (C.S.-M.); (B.J.); (F.R.); (P.W.); (F.M.B.); (M.H.); (C.W.); (F.S.)
| | - Bertram Jehs
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (J.A.D.); (S.B.); (C.S.-M.); (B.J.); (F.R.); (P.W.); (F.M.B.); (M.H.); (C.W.); (F.S.)
| | - Franka Risch
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (J.A.D.); (S.B.); (C.S.-M.); (B.J.); (F.R.); (P.W.); (F.M.B.); (M.H.); (C.W.); (F.S.)
| | - Piotr Woźnicki
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (J.A.D.); (S.B.); (C.S.-M.); (B.J.); (F.R.); (P.W.); (F.M.B.); (M.H.); (C.W.); (F.S.)
| | - Franziska M. Braun
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (J.A.D.); (S.B.); (C.S.-M.); (B.J.); (F.R.); (P.W.); (F.M.B.); (M.H.); (C.W.); (F.S.)
| | - Mark Haerting
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (J.A.D.); (S.B.); (C.S.-M.); (B.J.); (F.R.); (P.W.); (F.M.B.); (M.H.); (C.W.); (F.S.)
| | - Claudia Wollny
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (J.A.D.); (S.B.); (C.S.-M.); (B.J.); (F.R.); (P.W.); (F.M.B.); (M.H.); (C.W.); (F.S.)
| | - Thomas J. Kroencke
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (J.A.D.); (S.B.); (C.S.-M.); (B.J.); (F.R.); (P.W.); (F.M.B.); (M.H.); (C.W.); (F.S.)
| | - Florian Schwarz
- Department of Diagnostic and Interventional Radiology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany; (J.A.D.); (S.B.); (C.S.-M.); (B.J.); (F.R.); (P.W.); (F.M.B.); (M.H.); (C.W.); (F.S.)
- Faculty of Medicine, Ludwig Maximilian University of Munich, Geschwister-Scholl-Platz 1, 80539 Munich, Germany
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7
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Meurer F, Kopp F, Renz M, Harder FN, Leonhardt Y, Bippus R, Noël PB, Makowski MR, Sauter AP. Sparse-sampling computed tomography for detection of endoleak after endovascular aortic repair (EVAR). Eur J Radiol 2021; 142:109843. [PMID: 34274842 DOI: 10.1016/j.ejrad.2021.109843] [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: 11/12/2020] [Revised: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To evaluate sparse sampling computed tomography (SpSCT) for detection of endoleak after endovascular aortic repair (EVAR) at different dose levels in terms of subjective image criteria and diagnostic accuracy. METHODS Twenty clinically indicated computed tomography aortic angiography (CTA) scans were used to obtain simulated low-dose scans with 100%, 50%, 25%, 12.5% and 6.25% of the applicated clinical dose, resulting in five dose levels (DL). From full sampling (FS) data sets, every second (2-SpSCT) or fourth (4-SpSCT) projection was used to generate simulated sparse sampling scans. All examinations were evaluated by four blinded radiologists regarding subjective image criteria and diagnostic performance. RESULTS Sensitivity was higher than 93% in 4-SpSCT at the 25% DL which is the same as with FS at full dose (100% DL). High accuracies and relative high AUC-values were obtained for 2- and 4-SpSCT down to the 12.5% DL, while for FS similar values were shown down to 25% DL only. Subjective image quality was significantly higher for 4-SpSCT compared to FS at each dose level. More than 90% of all cases were rated with a high or medium confidence for FS and 2-SpSCT at the 50% DL and for 4-SpSCT at the 25% DL. At DL 25% and 12.5%, more cases showed a high confidence using 2- and 4-SpSCT compared with FS. CONCLUSIONS Via SpSCT, a dose reduction down to a 25% dose level (mean effective dose of 1.49 mSv in the current study) for CTA is possible while maintaining high image quality and full diagnostic confidence.
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Affiliation(s)
- Felix Meurer
- Klinikum rechts der Isar, School of Medicine Technical University of Munich, Institute of Diagnostic and Interventional Radiology, Munich, Germany.
| | - Felix Kopp
- Klinikum rechts der Isar, School of Medicine Technical University of Munich, Institute of Diagnostic and Interventional Radiology, Munich, Germany
| | - Martin Renz
- Klinikum rechts der Isar, School of Medicine Technical University of Munich, Institute of Diagnostic and Interventional Radiology, Munich, Germany
| | - Felix N Harder
- Klinikum rechts der Isar, School of Medicine Technical University of Munich, Institute of Diagnostic and Interventional Radiology, Munich, Germany
| | - Yannik Leonhardt
- Klinikum rechts der Isar, School of Medicine Technical University of Munich, Institute of Diagnostic and Interventional Radiology, Munich, Germany
| | - Rolf Bippus
- Philips Technologie GmbH Innovative Technologies, Research Laboratories, Hamburg, Germany
| | - Peter B Noël
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Markus R Makowski
- Klinikum rechts der Isar, School of Medicine Technical University of Munich, Institute of Diagnostic and Interventional Radiology, Munich, Germany
| | - Andreas P Sauter
- Klinikum rechts der Isar, School of Medicine Technical University of Munich, Institute of Diagnostic and Interventional Radiology, Munich, Germany
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Montelione N, Sirignano P, d'Adamo A, Stilo F, Mansour W, Capoccia L, Nenna A, Spinelli F, Speziale F. Comparison of Outcomes Following EVAR Based on Aneurysm Diameter and Volume and Their Postoperative Variations. Ann Vasc Surg 2021; 74:183-193. [PMID: 33549787 DOI: 10.1016/j.avsg.2020.12.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE to evaluate the impact of bi- and 3-dimensional preoperative aortic morphological features and their immediate postoperative variations on the outcome of abdominal aortic aneurysms (AAA) treated by endovascular exclusion with standard devices (EVAR). MATERIALS AND METHODS Double centre retrospective analysis of prospectively collected registry data of EVAR patients. For all patients, preoperative and 30-day computed tomographic angiography images (CTA) were reviewed. Preoperative maximum AAA diameter >59 mm and volume >159 cm3, and any 30-day postoperative increasing at CTA, were considered as potentially influencing the outcome. The outcome measures were: primary technical success; 30-day, 1-year, and mean follow-up reintervention, all-cause and AAA-related mortality rates, and also endoleak-related reinterventions. RESULTS Three hundred and thrity-three patients were enrolled. Mean preoperative and 30-day AAA diameter and volume were 50.4 mm ± 11.8 vs. 49.1 mm ± 12.1, and 112.9 cm3 ± 79.5 vs. 112.1 cm3 ± 80.5, respectively. Primary technical success was achieved in all cases. At 34.9 months follow-up, cumulative reintervention rate was 12.0%, mortality rates 7.2%, without AAA-related deaths. Endoleak-related reintervention rate was 7.5%. At uni- and multi-variate analysis, preoperative AAA diameter >59 mm, and AAA volume >159 cm3 were significantly associated to reintervention (P = 0.012; P = 0.002), and reintervention and death (P = 0.002; P = 0.001) during follow-up. Additionally, any increase in postoperative AAA diameter or volume was significantly associated with reintervention (P = 0.001, P = 0.001) and reintervention and death (P = 0.006, P = 0.001). Endoleak-related reintervention were also significantly associated with all of the analysed morphological parameters (P = 0.019, P = 0.005, P = 0.005, and P = 0.002, respectively). CONCLUSIONS Patients with larger baseline AAA size and volume as well as unfavourable early remodelling of the sac are associated to worse long-term EVAR outcome.
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Affiliation(s)
- Nunzio Montelione
- Vascular Surgery Division, University of Campus Bio-Medico, Rome, Italy.
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
| | - Alessandro d'Adamo
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, University of Campus Bio-Medico, Rome, Italy
| | - Wassim Mansour
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
| | - Laura Capoccia
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
| | - Antonio Nenna
- Department of Cardiovascular Surgery, University of Campus Bio-Medico, Rome, Italy
| | | | - Francesco Speziale
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
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Schlieder I, Kontopidis I, Blackwood S, Krol E, Dietzek AM. Increasing disparity between Society for Vascular Surgery guidelines for infrarenal abdominal aortic aneurysm repair and real-world practice. J Vasc Surg 2020; 73:1227-1233.e1. [PMID: 32889077 DOI: 10.1016/j.jvs.2020.08.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 08/04/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The current Society for Vascular Surgery (SVS) guidelines, based on randomized controlled trials published more than a decade ago, recommend a minimum threshold diameter of 5.5 cm for infrarenal abdominal aortic aneurysm (iAAA) repair. It is unknown whether practice patterns with respect to size of repair have changed since the publication of these guidelines. We aimed to evaluate the real-world practice of vascular surgeons in our region with respect to iAAA size at the time of repair, whether this has changed over the past 12 years and if any changes were associated with the repair type, open vs endovascular. METHODS The Vascular Study Group of New England (VSGNE) database was used to identify all patients who received iAAA repair between 2003 and 2015. The primary end point was to quantify the annual percentage of iAAAs repaired in different size categories (≥5.5 cm; <5.5 cm but ≥5.0 cm; <5.0 cm) over the study time period and by type of repair. The secondary end points were morbidity and mortality in these groups. We excluded nonelective cases (ruptured or symptomatic), patients with coexisting iliac artery aneurysms, and those missing critical data. RESULTS A total of 5314 patients with iAAA repairs (1538 open, 3776 endovascular) were identified in the VSGNE database during the study period. In 40% (2110 of 5314) of patients, repair was performed for aneurysms <5.5 cm, with endovascular aneurysm repair (EVAR) comprising 75% (1581 of 2110) and open 25% (529 of 2110). More EVARs were performed for <5.5 cm in 2015 (46%) compared with 2003 (33%) (P < .05, n - 1 χ2) with an average increase of 1.1%/y. There was also a non-statistically significant increase in open repair of small aneurysms (0.7%/y; P = .759). Overall, 30-day mortality was 1.11% in the EVAR group (0.54% in <5.0 cm, 0.91% in ≥5.0 but <5.5 cm, and 1.55% in ≥5.5 cm), compared with 3% in the open group (2.88%, 1.79%, and 3.77%, respectively) with no significant change in mortality in either group over time. CONCLUSIONS Despite the SVS guidelines suggesting surveillance rather than repair of iAAA <5.5 cm, an increasing proportion of repairs in the VSGNE database were performed below that threshold. The reasons for this are likely multifactorial and might include a lesser complexity and lower operative mortality for smaller aneurysms and markedly improved third- and fourth-generation stent graft technology with possibly better long-term survival. As such, it may be time to re-examine the current guidelines for iAAA repair.
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Affiliation(s)
- Ian Schlieder
- Department of Vascular Surgery, Danbury Hospital, Danbury, Conn
| | | | | | - Emilia Krol
- Department of Vascular Surgery, Danbury Hospital, Danbury, Conn
| | - Alan M Dietzek
- Department of Vascular Surgery, Danbury Hospital, Danbury, Conn.
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10
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Chang RW, Rothenberg KA, Harris JE, Gologorsky RC, Hsu JH, Rehring TF, Hajarizadeh H, Nelken NA, Paxton EW, Prentice HA. Midterm outcomes for 605 patients receiving Endologix AFX or AFX2 Endovascular AAA Systems in an integrated healthcare system. J Vasc Surg 2020; 73:856-866. [PMID: 32623106 DOI: 10.1016/j.jvs.2020.06.048] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/04/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Endologix issued important safety updates for the AFX Endovascular AAA System in 2016 and 2018 owing to the risk of type III endoleaks. Outcomes with these devices are limited to small case series with short-term follow-up. We describe the midterm outcomes for a large cohort of patients who received an Endologix AFX or AFX2 device. STUDY DESIGN Data from an integrated healthcare system's implant registry, which prospectively monitors all patients after endovascular aortic repair, was used for this descriptive study. Patients undergoing endovascular aortic repair with three AFX System variations (Strata [AFX-S], Duraply [AFX-D], and AFX2 with Duraply [AFX2]) were identified (2011-2017). Crude cumulative event probabilities for endoleak (types I and III), major reintervention, conversion to open, rupture, and mortality (aneurysm related and all cause) were estimated. RESULTS Among 605 patients, 375 received AFX-S, 197 received AFX-D, and 33 received AFX2. Median follow-up for the cohort was 3.9 (interquartile range, 2.5-5.1) years. The crude 2-year incidence of overall endoleak, any subsequent reintervention or conversion, and mortality was 8.8% (95% confidence interval [CI], 6.3-12.3), 12.0% (95% CI, 9.1-15.9), and 8.8% (95% CI, 6.3-12.2) for AFX-S. Respective estimates for AFX-D were 7.9% (95% CI, 4.8-13.0), 10.6% (95% CI, 6.9-16.1), and 9.7% (95% CI, 6.3-14.7); for AFX2, they were 14.1% (95% CI, 4.7-38.2), 16.2% (95% CI, 6.4-37.7), and 21.2% (95% CI, 10.7-39.4). CONCLUSIONS The midterm outcomes of a large U.S. patient cohort with an Endologix AFX or AFX2 System demonstrate a concerning rate of adverse postoperative events. Patients with these devices should receive close clinical surveillance to prevent device-related adverse events.
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Affiliation(s)
- Robert W Chang
- Department of Vascular Surgery, The Permanente Medical Group, South San Francisco, Calif; Division of Research, Kaiser Permanente Northern California, Oakland, Calif.
| | - Kara A Rothenberg
- Department of Surgery, University of California San Francisco - East Bay, Oakland, Calif
| | - Jessica E Harris
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, Calif
| | - Rebecca C Gologorsky
- Department of Surgery, University of California San Francisco - East Bay, Oakland, Calif
| | - Jeffrey H Hsu
- Department of Vascular Surgery, Southern California Permanente Medical Group, Fontana
| | - Thomas F Rehring
- Department of Vascular Surgery, Colorado Permanente Medical Group, Denver, Colo
| | - Homayon Hajarizadeh
- Department of Vascular Surgery, Northwest Permanente Physicians and Surgeons, Clackamas, Ore
| | - Nicolas A Nelken
- Department of Vascular Surgery, Hawaii Permanente Medical Group, Honolulu, Hawaii
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11
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Sirignano P, Mansour W, Baldassarre V, Porreca CF, Cuozzo S, Miceli F, Capoccia L, Sbarigia E, Speziale F. Infrarenal Abdominal Aortic Aneurysm Endovascular Treatment: Long-term Results From a Single-Center Experience in an Unselected Patient Population. Ann Vasc Surg 2020; 67:274-282. [PMID: 32209404 DOI: 10.1016/j.avsg.2020.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The aim of the present study was to evaluate early-, mid-, and long-term outcomes in an unselected population of patients treated for abdominal aortic aneurysms (AAAs) by endovascular aneurysm repair (EVAR) with different commercially available off-the-shelf devices. MATERIALS AND METHODS A retrospective study was conducted on a prospectively compiled computerized database on patients presenting an infrarenal AAA treated between January 2008 and December 2015 in a high-volume Italian tertiary referral Center. Demographic, clinical, and specific morphological features were considered as potentially influencing the outcomes and the type of the implanted device. Outcome measures were procedure-related reintervention, AAA-related, and all-cause mortality rates at 30-day, 12-month, and long-term follow-up. Reinterventions considered for the analysis were AAA rupture, graft infection, type I or III endoleaks, type II endoleaks with sac enlargement > 5 mm, graft stenosis or occlusions, procedures related to renal or visceral ischemia, and reintervention for access vessel injury. RESULTS Of 498 EVAR procedures performed for elective infrarenal AAA treatment during the entire study period, 479 patients were enrolled, the mean age was 73.5 ± 7.34 years (range 51-91), and 416 (86.84%) were men. The mean maximum AAA diameter was 52.02 ± 8.04 mm (range 39-90.2), a maximum AAA diameter ≥59 mm was recorded in 107 patients (22.33%), and an aortic neck length was <10 mm in 137 (28.60%). Technical success was achieved in all patients. At a mean follow-up of 52.97 ± 26.16 months (range 1-120), overall reintervention and death rates were 8.14% and 20.04%, respectively, without AAA-related deaths. At univariate analysis, hypertension was the only demographical variable found to be associated with higher risk of reintervention, P = 0.04 (OR: 2.34; CI 95%: 1.00-5.42). Furthermore, male sex (P = 0.02; OR: 2.62; CI 95%: 1.09-6.27) and chronic renal insufficiency (P = 0.003; OR: 2.08; CI 95%: 1.27-3.42) were associated with higher mortality rates. AAA diameter ≥59 mm was statistically associated with a higher rate of both reintervention and mortality: P < 0.001 (OR: 9.05; CI 95%: 4.52-18.11) and <0.001 (4.00; 2.46-6.49), respectively. CONCLUSIONS Our experience seems to suggest that EVAR could be safely and effectively performed in an unselected patients' population, with encouraging results up to a ten-year follow-up.
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Affiliation(s)
- Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Department of Surgery "Paride Stefanini", Policlinico Umberto I of Rome, "Sapienza" University of Rome, Rome, Italy.
| | - Wassim Mansour
- Vascular and Endovascular Surgery Unit, Department of Surgery "Paride Stefanini", Policlinico Umberto I of Rome, "Sapienza" University of Rome, Rome, Italy
| | - Virgilio Baldassarre
- Vascular and Endovascular Surgery Unit, Department of Surgery "Paride Stefanini", Policlinico Umberto I of Rome, "Sapienza" University of Rome, Rome, Italy
| | - Carlo Filippo Porreca
- Vascular and Endovascular Surgery Unit, Department of Surgery "Paride Stefanini", Policlinico Umberto I of Rome, "Sapienza" University of Rome, Rome, Italy
| | - Simone Cuozzo
- Vascular and Endovascular Surgery Unit, Department of Surgery "Paride Stefanini", Policlinico Umberto I of Rome, "Sapienza" University of Rome, Rome, Italy
| | - Francesca Miceli
- Vascular and Endovascular Surgery Unit, Department of Surgery "Paride Stefanini", Policlinico Umberto I of Rome, "Sapienza" University of Rome, Rome, Italy
| | - Laura Capoccia
- Vascular and Endovascular Surgery Unit, Department of Surgery "Paride Stefanini", Policlinico Umberto I of Rome, "Sapienza" University of Rome, Rome, Italy
| | - Enrico Sbarigia
- Vascular and Endovascular Surgery Unit, Department of Surgery "Paride Stefanini", Policlinico Umberto I of Rome, "Sapienza" University of Rome, Rome, Italy
| | - Francesco Speziale
- Vascular and Endovascular Surgery Unit, Department of Surgery "Paride Stefanini", Policlinico Umberto I of Rome, "Sapienza" University of Rome, Rome, Italy
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12
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Jones DW, Deery SE, Schneider DB, Rybin DV, Siracuse JJ, Farber A, Schermerhorn ML. Differences in patient selection and outcomes based on abdominal aortic aneurysm diameter thresholds in the Vascular Quality Initiative. J Vasc Surg 2019; 70:1446-1455. [DOI: 10.1016/j.jvs.2019.02.053] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/20/2019] [Indexed: 11/25/2022]
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13
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Wang SK, Lemmon GW, Gupta AK, Dalsing MC, Sawchuk AP, Motaganahalli RL, Murphy MP, Fajardo A. Aggressive Surveillance Is Needed to Detect Endoleaks and Junctional Separation between Device Components after Zenith Fenestrated Aortic Reconstruction. Ann Vasc Surg 2019; 57:129-136. [PMID: 30684629 DOI: 10.1016/j.avsg.2018.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 09/22/2018] [Accepted: 09/26/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Junctional separation and resulting type IIIa endoleak is a well-known problem after EVAR (endovascular aneurysm repair). This complication results in sac pressurization, enlargement, and eventual rupture. In this manuscript, we review the incidence of this late finding in our experience with the Cook Zenith fenestrated endoprosthesis (ZFEN, Bloomington, IN). METHODS A retrospective review was performed of a prospectively maintained institutional ZFEN fenestrated EVAR database capturing all ZFENs implanted at a large-volume, academic hospital system. Patients who experienced junctional separation between the fenestrated main body and distal bifurcated graft (with or without type IIIa endoleak) at any time after initial endoprosthesis implantation were subject to further evaluation of imaging and medical records to abstract clinical courses. RESULTS In 110 ZFENs implanted from October 2012 to December 2017 followed for a mean of 1.5 years, we observed a 4.5% and 2.7% incidence of clinically significant junctional separation and type IIIa endoleak, respectively. Junctional separation was directly related to concurrent type Ib endoleak in all 5 patients. Three patients presented with sac enlargement. One patient did not demonstrate any evidence of clinically significant endoleak and had a decreasing sac size during follow-up imaging. The mean time to diagnosis of modular separation in these patients was 40 months. Junctional separation was captured in surveillance in 2 patients and reintervened upon before manifestation of endoleak. However, the remaining 3 patients completed modular separation resulting in rupture and emergent intervention in 2 and an aortic-related mortality in the other. CONCLUSIONS Junctional separation between the fenestrated main and distal bifurcated body with the potential for type IIIa endoleak is an established complication associated with the ZFEN platform. Therefore, we advocate for maximizing aortic overlap during the index procedure followed by aggressive surveillance and treatment of stent overlap loss captured on imaging.
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Affiliation(s)
- Shihuan Keisin Wang
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN.
| | - Gary W Lemmon
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Alok K Gupta
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael C Dalsing
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Alan P Sawchuk
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Raghu L Motaganahalli
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael P Murphy
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Andres Fajardo
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN.
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14
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Hye RJ, Janarious AU, Chan PH, Cafri G, Chang RW, Rehring TF, Nelken NA, Hill BB. Survival and Reintervention Risk by Patient Age and Preoperative Abdominal Aortic Aneurysm Diameter after Endovascular Aneurysm Repair. Ann Vasc Surg 2018; 54:215-225. [PMID: 30081171 DOI: 10.1016/j.avsg.2018.05.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 05/01/2018] [Accepted: 05/10/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) has become the standard of care for abdominal aortic aneurysm (AAA), but questions remain regarding the benefit in high-risk and elderly patients. The purpose of this study was to examine the effect of age, preoperative AAA diameter, and their interaction on survival and reintervention rates after EVAR. METHODS Our integrated health system's AAA endograft registry was used to identify patients who underwent elective EVAR between 2010 and 2014. Of interest was the effect of patient age at the time of surgery (≤80 vs. >80 years old), preoperative AAA diameter (≤5.5 cm vs. >5.5 cm), and their interaction. Primary endpoints were all-cause mortality and reintervention. Between-within mixed-effects Cox models with propensity score weights were fit. RESULTS Of 1,967 patients undergoing EVAR, unadjusted rates for survival at 4 years after EVAR was 76.1%, and reintervention-free rate was 86.0%. For mortality, there was insufficient evidence for an interaction between age and AAA size (P = 0.309). Patient age >80 years was associated with 2.53-fold higher mortality risk (hazard ratios [HR] = 2.53; 95% confidence intervals [CI], 1.73-3.70; P < 0.001), whereas AAA > 5.5 cm was associated with 1.75-fold higher mortality risk (HR = 1.75; 95% CI, 1.26-2.45; P = 0.001). For reintervention risk, there were no significant interactions or main effects for age or AAA diameter. CONCLUSIONS Age and AAA diameter are independent predictors of reduced survival after EVAR, but the effect is not amplified when both are present. Age >80 years or AAA size >5.5 cm did not increase the risk of reintervention. No specific AAA size, patient age, or combination thereof was identified that would contraindicate AAA repair.
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Affiliation(s)
- Robert J Hye
- Department of Surgery, Southern California Permanente Medical Group, San Diego, CA
| | - Afra U Janarious
- Department of Surgery, Southern California Permanente Medical Group, San Diego, CA
| | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA
| | - Guy Cafri
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA
| | - Robert W Chang
- Department of Surgery, The Permanente Medical Group, South San Francisco, CA
| | - Thomas F Rehring
- Department of Vascular Surgery, Colorado Permanente Medical Group, Denver, CO
| | - Nicolas A Nelken
- Department of Vascular Therapy, Hawaii Permanente Group, Honolulu, HI
| | - Bradley B Hill
- Department of Vascular Surgery, The Permanente Medical Group, Santa Clara, CA.
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15
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Tomee SM, Bastiaannet E, Schermerhorn ML, Golledge J, Hamming JF, Lindeman JH. The Consequences of Real Life Practice of Early Abdominal Aortic Aneurysm Repair: A Cost-Benefit Analysis. Eur J Vasc Endovasc Surg 2017; 54:28-33. [PMID: 28506561 DOI: 10.1016/j.ejvs.2017.03.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 03/29/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND The reported 54 mm median intervention diameter for endovascular aneurysm repair (EVAR) in the Vascular Quality Initiative and European data from the Pharmaceutical Aneurysm Stabilisation Trial (PHAST) implies that in real life the majority of abdominal aortic aneurysm (AAA) repairs occur at diameters smaller than the consensus intervention threshold of 55 mm. This study explores the potential consequences of this practice. METHODS The differences between real life AAA repair and consensus based intervention threshold were explored in reported data from vascular quality initiatives and PHAST. The subsequent consequences of advancement of endovascular aneurysm repair (EVAR) were estimated using a multistate model based on life tables for the EVAR Medicare population. RESULTS There appears an approximate 5 mm difference in AAA diameter between real life practice and consensus intervention threshold. Assuming a 2.5 mm annual growth rate, this results in an approximately 2 year advancement of AAA repair. According to the model used, early repair reduces overall small aneurysm patient mortality by 2.3%, it results in 21.9% more EVAR procedures, more EVAR related deaths, and 42.3% and 36.8% more open and endovascular re-interventions, respectively. Cost-benefit estimates imply 482 fewer AAA related deaths, but 140 extra EVAR related deaths for a population of more than 30,000 AAA patients, and a 300 million USD increase in health costs for the 8 year observation period in the Medicare population. CONCLUSIONS In the real life situation a large proportion of EVAR procedures appear to occur before reaching the consensus threshold. Although this reduces mortality, it comes at a cost of approximately 1 million USD per prevented rupture related death.
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Affiliation(s)
- S M Tomee
- Department of Surgery, Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - E Bastiaannet
- Department of Surgery, Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - M L Schermerhorn
- Department of Surgery, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - J Golledge
- The Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Australia; Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Australia
| | - J F Hamming
- Department of Surgery, Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - J H Lindeman
- Department of Surgery, Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Centre, Leiden, The Netherlands.
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16
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Huang Y, Gloviczki P, Duncan AA, Kalra M, Oderich GS, Fleming MD, Harmsen WS, Bower TC. Maximal aortic diameter affects outcome after endovascular repair of abdominal aortic aneurysms. J Vasc Surg 2017; 65:1313-1322.e4. [DOI: 10.1016/j.jvs.2016.10.093] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 10/17/2016] [Indexed: 11/30/2022]
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17
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Lemmon GW, Motaganahalli RL, Chang T, Slaven J, Aumiller B, Kim BJ, Dalsing MC. Failure mode analysis of the Endologix endograft. J Vasc Surg 2016; 64:571-6. [DOI: 10.1016/j.jvs.2016.03.416] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 03/08/2016] [Indexed: 11/30/2022]
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18
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Khashram M, Hider PN, Williman JA, Jones GT, Roake JA. Does the diameter of abdominal aortic aneurysm influence late survival following abdominal aortic aneurysm repair? A systematic review and meta-analysis. Vascular 2016; 24:658-667. [DOI: 10.1177/1708538116650580] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Studies reporting the influence of preoperative abdominal aortic aneurysm diameter on late survival following abdominal aortic aneurysm repair have not been consistent. Aim: To report the influence of abdominal aortic aneurysm diameter on overall long-term survival following abdominal aortic aneurysm repair. Methods Embase, Medline and the Cochrane electronic databases were searched to identify articles reporting the influence of abdominal aortic aneurysm diameter on late survival following open aneurysm repair and endovascular aneurysm repair published up to April 2015. Data were extracted from multivariate analysis; estimated risks were expressed as hazard ratio. Results A total of 2167 titles/abstracts were retrieved, of which 76 studies were fully assessed; 19 studies reporting on 22,104 patients were included. Preoperative larger abdominal aortic aneurysm size was associated with a worse survival compared to smaller aneurysms with a pooled hazard ratio of 1.14 (95% CI: 1.09–1.18), per 1 cm increase in abdominal aortic aneurysm diameter. Subgroup analysis of the different types of repair was performed and the hazard ratio (95% CI), for open aneurysm repair and endovascular aneurysm repair were 1.08 (1.03–1.12) and 1.20 (1.15–1.25), respectively, per 1 cm increase. There was a significant difference between the groups p < 0.02. Conclusions This meta-analysis suggests that preoperative large abdominal aortic aneurysm independently influences overall late survival following abdominal aortic aneurysm repair, and this association was greater in abdominal aortic aneurysm repaired with endovascular aneurysm repair.
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Affiliation(s)
- Manar Khashram
- Department of Surgery, University of Otago, Christchurch, New Zealand
- Department of Vascular Endovascular & Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Phil N Hider
- Department of Population Health, University of Otago, Christchurch, New Zealand
| | - Jonathan A Williman
- Department of Population Health, University of Otago, Christchurch, New Zealand
| | - Gregory T Jones
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Christchurch, New Zealand
| | - Justin A Roake
- Department of Vascular Endovascular & Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
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de Bruin JL, Karthikesalingam A, Holt PJ, Prinssen M, Thompson MM, Blankensteijn JD, Grobbee D, Blankensteijn J, Bak A, Buth J, Pattynama P, Verhoeven E, van Voorthuisen A, Blankensteijn J, Balm R, Buth J, Cuypers P, Grobbee D, Prinssen M, van Sambeek M, Verhoeven E, Baas A, Hunink M, van Engelshoven J, Jacobs M, de Mol B, van Bockel J, Balm R, Reekers J, Tielbeek X, Verhoeven E, Wisselink W, Boekema N, Heuveling L, Sikking I, Prinssen M, Balm R, Blankensteijn J, Buth J, Cuypers P, van Sambeek M, Verhoeven E, de Bruin J, Baas A, Blankensteijn J, Prinssen M, Buth J, Tielbeek A, Blankensteijn J, Balm R, Reekers J, van Sambeek M, Pattynama P, Verhoeven E, Prins T, van der Ham A, van der Velden J, van Sterkenburg S, ten Haken G, Bruijninckx C, van Overhagen H, Tutein Nolthenius R, Hendriksz T, Teijink J, Odink H, de Smet A, Vroegindeweij D, van Loenhout R, Rutten M, Hamming J, Lampmann L, Bender M, Pasmans H, Vahl A, de Vries C, Mackaay A, van Dortmont L, van der Vliet A, Schultze Kool L, Boomsma J, van H, de Mol van Otterloo J, de Rooij T, Smits T, Yilmaz E, Wisselink W, van den Berg F, Visser M, van der Linden E, Schurink G, de Haan M, Smeets H, Stabel P, van Elst F, Poniewierski J, Vermassen F. Predicting reinterventions after open and endovascular aneurysm repair using the St George's Vascular Institute score. J Vasc Surg 2016; 63:1428-1433.e1. [DOI: 10.1016/j.jvs.2015.12.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/15/2015] [Indexed: 12/01/2022]
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Sirignano P, Menna D, Capoccia L, Montelione N, Mansour W, Rizzo AR, Sbarigia E, Speziale F. Preoperative Intrasac Thrombus Load Predicts Worse Outcome after Elective Endovascular Repair of Abdominal Aortic Aneurysms. J Vasc Interv Radiol 2015; 26:1431-6. [DOI: 10.1016/j.jvir.2015.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 07/02/2015] [Accepted: 07/04/2015] [Indexed: 11/24/2022] Open
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Hiraoka A, Chikazawa G, Ishida A, Miyake K, Totsugawa T, Tamura K, Sakaguchi T, Yoshitaka H. Impact of Age and Intraluminal Thrombus Volume on Abdominal Aortic Aneurysm Sac Enlargement after Endovascular Repair. Ann Vasc Surg 2015; 29:1440-6. [PMID: 26169457 DOI: 10.1016/j.avsg.2015.05.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 03/19/2015] [Accepted: 05/27/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Abdominal aneurysmal sac enlargement after endovascular aortic repair (EVAR) is a critical issue. However, the predictors have not yet been fully determined. Although unrecognized, intraluminal thrombus volume (ITV) is an important index. Therefore, we retrospectively evaluated the correlation among preoperative ITV, residual type II endoleak, and sac enlargement after EVAR, based on the long-term follow-up. METHODS Between 2006 and 2011, 151 consecutive patients underwent EVAR at a single cardiovascular institute. Emergency surgery was performed on 7 patients (4.7%). Of 148 patients excluding 3 patients with residual type I endoleak, sac enlargement (≥5 mm progression) after EVAR was observed in 24 patients (16.2%) and 8 patients required reintervention. The mean follow-up period was 2.4 ± 1.4 years. The outer volume and enhanced luminal volume were calculated from enhanced 1-mm slice computed tomography, and the difference was defined as ITV. RESULTS Age (hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.04-1.20, P = 0.0007), outer volume (HR 1.04, 95% CI 1.01-1.07, P = 0.0118), percentage of ITV (HR 0.90, 95% CI 0.84-0.96, P = .0027), and type II endoleak (HR 10.15, 95% CI 3.55-31.10, P < 0.0001) were isolated as predictors of sac enlargement by multivariate analysis. Also, patent inferior mesenteric artery (odds ratio [OR] 4.45, 95% CI 1.38-20.07, P = 0.0105) and percentage of ITV < 30.1% (OR 3.52, 95% CI 1.32-10.30, P = 0.0112) were detected as independent risk factors for residual type II endoleaks. Additionally, in patients without endoleak, patient age (≥83 years) was an independent risk factor for sac enlargement after EVAR (P = 0.0056). CONCLUSION Age and ITV percentage had significantly great impact on sac enlargement and type II endoleak after EVAR.
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Affiliation(s)
- Arudo Hiraoka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan.
| | - Genta Chikazawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Atsuhisa Ishida
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Koichi Miyake
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Toshinori Totsugawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Kentaro Tamura
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Hidenori Yoshitaka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan
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Management of late main-body aortic endograft component uncoupling and type IIIa endoleak encountered with the Endologix Powerlink and AFX platforms. J Vasc Surg 2015; 62:868-75. [PMID: 26141699 DOI: 10.1016/j.jvs.2015.04.454] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 04/29/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Junctional component separation producing type IIIa endoleak after endovascular abdominal aortic aneurysm repair (EVAR) is an uncommon but serious complication requiring unanticipated reinterventions. This retrospective study analyzed main-body EVAR component uncoupling and type IIIa endoleaks encountered with Powerlink and AFX (Endologix Inc, Irvine, Calif) endografts during an 8-year period. METHODS Type IIIa endoleaks were identified from a database of secondary interventions and clinical surveillance. Operative reports, medical records, and computed tomography studies were reviewed. Clinical and imaging characteristics were analyzed over time, and differences were compared at appropriate follow-up intervals. RESULTS Since 2006, 701 patients underwent primary EVAR using Endologix Powerlink (352 patients, 2006-2011) or AFX (349 patients, 2011-2014) endografts. Endoleaks required 32 secondary interventions (4.6%), including type Ia in 4 patients (1 proximal extension and 3 explants); type Ib in 8 patients (all distal extensions for enlarging iliac aneurysms); type II in 1 patient (explant); type IIIa in 17 patients (2.4%), who were the subject of this report; and type IIIb in 2 patients (both EVAR relining). The 17 patients with type IIIa endoleak were an average age of 71 years, and 14 (82%) were men. The mean preoperative abdominal aortic aneurysm (AAA) diameter was 70 ± 18 mm. The repair was elective in 16 patients and an emergency in one. Ten cases were performed with Powerlink and seven with AFX. Analysis of serial computed tomography scans found significant changes in AAA diameter; renal-to-bifurcation straight-line, centerline, and greater curvature lengths; EVAR angulation; and loss of EVAR component overlap. The average time from EVAR to reintervention was 32 months. Three patients returned with a ruptured AAA and three with AAA thrombosis, and three of these patients (18%) died ≤30 days of the emergency reintervention. Secondary procedures included EVAR relining with additional bridging components in 14 patients (82%), explant in 2, and axillobifemoral bypass in 1. No new cases of endograft uncoupling have been identified in patients treated with AFX since December 2012 after adoption of revised instructions for use. CONCLUSIONS Although a small number of secondary interventions were needed after EVAR with the Endologix Powerlink or AFX endografts, most were undertaken for late main-body component uncoupling and type IIIa endoleak, which can occur after sideways displacement of the endograft in large and angulated AAAs. Patients treated before 2013 under the old instructions for use should be evaluated for signs of impending component separation and monitored annually, noting that expected indicators of endograft failure, such as increasing AAA diameter and endoleak, may be absent.
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Reply to the letter to the editor. Endoleak after endovascular aortic repair and lumbar vertebral erosion. J Orthop Traumatol 2015; 16:77-8. [PMID: 25716050 PMCID: PMC4348499 DOI: 10.1007/s10195-015-0336-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/22/2015] [Indexed: 11/27/2022] Open
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Bastos Goncalves F, Hoeks S, Teijink J, Moll F, Castro J, Stolker R, Forbes T, Verhagen H. Risk Factors for Proximal Neck Complications After Endovascular Aneurysm Repair Using the Endurant Stentgraft. Eur J Vasc Endovasc Surg 2015; 49:156-62. [DOI: 10.1016/j.ejvs.2014.10.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
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Dua A, Algodi MM, Furlough C, Ray H, Desai SS. Development of a scoring system to estimate mortality in abdominal aortic aneurysms management. Vascular 2014; 23:586-91. [PMID: 25492573 DOI: 10.1177/1708538114563825] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION This study aimed to define risk factors associated with inpatient mortality in patients undergoing elective repair for unruptured abdominal aortic aneurysm and utilize these factors to create a scoring system to estimate risk of mortality. METHODS A retrospective analysis was completed using the Nationwide Inpatient Sample from 1998 to 2011. Patients who underwent elective abdominal aortic aneurysm repair were identified using ICD-9 codes. Demographics, comorbidities, length of stay, insurance status, and mortality were recorded. Statistically significant variables were identified using a multivariate analysis, and a discriminant analysis was used to identify factors predictive of inpatient mortality. RESULTS Over a 14-year period, 28,448 patients underwent elective repair of an unruptured abdominal aortic aneurysm. Independent variables associated with inpatient mortality included: age >60, female gender, congestive heart failure, peripheral artery disease, renal failure, malnutrition, and hypercoagulability. Endovascular aneurysm repair was protective against inpatient mortality. The area under the curve for the discriminant function was 0.83 (95% CI, 0.81-0.85) and successfully classified 87.9% of patients within the Nationwide Inpatient Sample (25,006/28,448 patients). CONCLUSION Seven factors that predict an increased risk of mortality and one factor that decreased the risk of mortality were identified. Preoperative risk factor mitigation may improve mortality following elective abdominal aortic aneurysm repair.
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Affiliation(s)
- Anahita Dua
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mohammed M Algodi
- Department of Cardiology Research, Montefiore Medical Center, New York, NY, USA
| | | | - Hunter Ray
- University of Texas Medical School at Houston, Houston, TX, USA
| | - Sapan S Desai
- Department of Vascular Surgery, Southern Illinois University, Springfield, IL, USA
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Perspectives, personal experiences and personalized threshold for intervention in abdominal aortic aneurysm. Indian J Thorac Cardiovasc Surg 2014. [DOI: 10.1007/s12055-014-0310-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Lederle FA. Regarding "Comparison of outcomes following endovascular repair of abdominal aortic aneurysms based on size threshold". J Vasc Surg 2014; 59:1476. [PMID: 24767282 DOI: 10.1016/j.jvs.2013.12.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 12/18/2013] [Accepted: 12/18/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Frank A Lederle
- Center for Chronic Disease Outcomes Research, VA Health Care System (111-O), Minneapolis, Minn
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Passman MA, Jordan WD. Reply: To PMID 23911249. J Vasc Surg 2014; 59:1476-7. [PMID: 24767281 DOI: 10.1016/j.jvs.2014.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 01/15/2014] [Accepted: 01/17/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - William D Jordan
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
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Kabbani LS, West CA, Viau D, Nypaver TJ, Weaver MR, Barth C, Lin JC, Shepard AD. Survival after repair of pararenal and paravisceral abdominal aortic aneurysms. J Vasc Surg 2014; 59:1488-94. [PMID: 24709440 DOI: 10.1016/j.jvs.2014.01.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 01/03/2014] [Accepted: 01/09/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this study was to review our 27-year clinical experience with open proximal abdominal aortic aneurysm repairs, with a focus on long-term survival. METHODS A retrospective cohort study was undertaken of all patients who underwent proximal abdominal aortic aneurysm repair between 1986 and 2013 at a tertiary care referral center. Demographics, operative variables, complications, and 30-day mortality were analyzed. Postoperative acute kidney injury was analyzed by the RIFLE (Risk, Injury, Failure, Loss, End-stage renal disease)/Acute Kidney Injury Network criteria. Long-term survival was assessed through review of electronic medical records and the Social Security Death Index. Associations between demographics and complications were investigated to determine predictors of long-term survival. RESULTS The study identified 245 patients. Mean age was 71 years (range, 38-92 years); 69% were men, and 88% were white. Aneurysm type was juxtarenal in 127 patients (52%), suprarenal in 68 patients (28%), and type IV thoracoabdominal in 50 patients (20%). In-hospital mortality was 3.3% (eight patients), and 30-day mortality was 2.9% (seven patients). At least one major complication occurred in 64% of the patients, which included the following: acute kidney injury, 60% (persistent acute kidney injury at discharge, however, was 28%, and hemodialysis at discharge was 1.6%); major pulmonary complications, 22%; myocardial infarction, 4%; visceral ischemia, 2%; and paraplegia, 0.5%. Median follow-up was 54 months. Kaplan-Meier survival estimates were 70% at 5 years and 43% at 10 years. Variables associated with poorer survival included congestive heart failure (hazard ratio [HR], 3.5; P < .001), chronic obstructive pulmonary disease (HR, 1.8; P < .002), and increased aneurysm size at presentation (HR, 1.1; P < .013). Persistent stage 3 acute kidney injury was associated with poor long-term survival. CONCLUSIONS Open surgical repair of proximal abdominal aortic aneurysms can be performed with low mortality. Acute kidney injury is the most frequent complication, but the need for hemodialysis at discharge is low. Long-term survival is favorable. These data should assist in establishing benchmarks for endovascular repair of complex proximal abdominal aortic aneurysms.
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Affiliation(s)
- Loay S Kabbani
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, Mich.
| | - Charles A West
- Department of Cardiothoracic and Vascular Surgery, Baylor College of Medicine, Houston, Tex
| | - David Viau
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, Mich
| | | | | | - Charlotte Barth
- Center for Public Health Sciences, Henry Ford Health System, Detroit, Mich
| | - Judith C Lin
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, Mich
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