1
|
Fornasari A, Perini P, Gargiulo M, Silingardi R, Michelagnoli S, Bonardelli S, Bellosta R, Freyrie A. Endograft Thrombosis as an Indication for Open Conversion after Endovascular Aneurysm Repair in a Multicenter Experience over 25 Years. Ann Vasc Surg 2024; 108:157-165. [PMID: 38944191 DOI: 10.1016/j.avsg.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/26/2024] [Accepted: 04/10/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND To describe the outcomes of aortic endograft thrombosis (AET) as an indication for open conversion (OC) after endovascular aortic aneurysm repair (EVAR) in a multicenter experience. METHODS This study retrospectively analyzed cases of OC for AET following EVAR across 12 Italian Vascular Surgery centers from 1997 to September 2022. The end points were as follows: 30-day mortality and major postoperative complications. Follow-up data included survival and aortic-related complications. RESULTS Sixteen patients (mean age: 68.6 ± 8.5 years) were included. The median elapsed time between EVAR and OC was 26.46 months (interquartile range: 13.8-45.9). Proximal aortic cross-clamping site was supraceliac in 8 out of 16 (50%) patients, and complete removal of the stentgraft was achieved in 75% of cases (12/16 patients). Reconstructions were aorto-bi-iliac grafts in 8 cases (50%), 7 aortobifemoral bypass grafts (43.8%), and 1 aortoaortic tube graft (6.3%). All patients were symptomatic at presentation (68.7% unilateral acute limb ischemia, 25% bilateral acute limb ischemia, 1 patient had chronic severe claudication). Thirty-day mortality was 12.5% (2/16 patients). The overall morbidity rate was 43.8% (7 of 16 patients). No specific risk factors for early mortality were found. The overall estimated survival rate was 80.4% at 1 year, 62.5% at 2 years, and 41.7% at 3 years. CONCLUSIONS OC for AET is typically reserved for complex cases that are not amenable to endovascular solutions. The frequent need for suprarenal clamping and complete endograft removal seems to be associated with high short-term mortality.
Collapse
Affiliation(s)
- Anna Fornasari
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paolo Perini
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy; Vascular Surgery, Cardio-Thoracic and Vascular Department, University Hospital of Parma, Parma, Italy.
| | - Mauro Gargiulo
- Vascular Surgery, University of Bologna, Department of Medical and Surgical Sciences, Bologna, Italy; Bologna Vascular Surgery Unit, IRCCS University Hospital S. Orsola, Bologna, Italy
| | - Roberto Silingardi
- Vascular Surgery, Department of Biomedical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Michelagnoli
- Vascular and Endovascular Surgery, Department of Surgery, USL Toscana Centro, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Stefano Bonardelli
- Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Raffaello Bellosta
- Vascular Surgery, Department of Surgery, "Poliambulanza" Foundation Hospital, Brescia, Italy
| | - Antonio Freyrie
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy; Vascular Surgery, Cardio-Thoracic and Vascular Department, University Hospital of Parma, Parma, Italy
| |
Collapse
|
2
|
Nana P, Spanos K, Apostolidis G, Haulon S, Kölbel T. Systematic review and meta-analysis of fenestrated or branched devices after previous open surgical aortic aneurysm repair. J Vasc Surg 2024; 79:1251-1261.e4. [PMID: 37757916 DOI: 10.1016/j.jvs.2023.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Despite open surgical repair (OSR) of abdominal aortic aneurysms being considered as a durable solution, disease progression and para-anastomotic aneurysms may require further repair, and fenestrated and branched endovascular aneurysm repair (F/BEVAR) may be applied to address these pathologies. The aim of this systematic review was to assess technical success, mortality, and morbidity (acute kidney injury, spinal cord ischemia) at 30 days, and mortality and reintervention rates during the available follow-up, in patients managed with F/BEVAR after previous OSR. METHODS The PRISMA statement was followed, and the study was pre-registered to the PROSPERO (CRD42022363214). The English literature was searched, via Ovid, using MEDLINE, EMBASE, and CENTRAL databases, through November 30, 2022. Observational studies and case series with ≥5 patients (2000-2022), reporting on F/BEVAR outcomes after OSR, were considered eligible. The Newcastle-Ottawa Scale and GRADE were used to assess the risk of bias and quality of evidence. The primary outcome was technical success, mortality, and morbidity at 30 days. Data on the outcomes of interest were synthesized using proportional meta-analysis. RESULTS The initial search yielded 1694 articles. Eight retrospective studies (476 patients) were considered eligible. In 78.3% of cases, disease progression set the indication for reintervention. Technical success was estimated at 96% (95% confidence interval [CI], 89%-98%; I2 = 0%; 95% prediction interval [PI], 79%-99%). Thirty-day mortality was 2% (95% CI, 1%-9%; I2 = 0%; 95% PI, 0%-28%). The estimated spinal cord ischemia and acute kidney injury rates were 3% (95% CI, 1%-9%; I2 = 0%; 95% PI, 0%-30%) and 6% (95% CI, 2%-15%; I2 = 0%; 95% PI, 1%-40%), respectively. During follow-up, overall mortality was 5% (95% CI, 2%-12%; I2 = 34%; 95% PI, 0%-45%) and aorta-related mortality was 1% (95% CI, 0%-2%; I2 = 0%; 95% PI, 0%-3%). The rate of reinterventions was 16% (95% CI, 9%-26%; I2 = 22%; 95% PI, 3%-50%). CONCLUSIONS According to the available literature, F/BEVAR after OSR may be performed with high technical success and low mortality and morbidity during the perioperative period. Follow-up aortic-related mortality was 1%, whereas the reintervention rates were within the standard range following F/BEVAR.
Collapse
Affiliation(s)
- Petroula Nana
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany.
| | - Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany; Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - George Apostolidis
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| |
Collapse
|
3
|
Giannakopoulos N, Antoniou A, Tzamtzidou S, Manou D, Papas T. Late Open Abdominal Aneurysm Reconstruction and Graft Salvage in a Patient With Persistent Endoleak Type II Following Endovascular Aneurysm Repair. Cureus 2024; 16:e61420. [PMID: 38947720 PMCID: PMC11214724 DOI: 10.7759/cureus.61420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2024] [Indexed: 07/02/2024] Open
Abstract
This study highlights a case of late open conversion repair (OCR) for persistent Type II endoleak after endovascular aneurysm repair (EVAR), presenting a 78-year-old male with a history of EVAR for an infrarenal abdominal aortic aneurysm. Despite conservative management of the initial endoleak, the aneurysm sac's progressive growth necessitated open reconstruction to salvage the graft. Successful postoperative outcomes emphasize the critical need for meticulous intervention strategies and surveillance in managing persistent Type II endoleaks. This case underlines the importance of a tailored approach, leveraging both endovascular and open surgical techniques, to optimize long-term outcomes and prevent aneurysm rupture in complex cases.
Collapse
Affiliation(s)
- Nikolaos Giannakopoulos
- Department of Vascular Surgery, Korgialenio-Benakio Hellenic Red Cross Hospital, Athens, GRC
| | - Afroditi Antoniou
- Department of Vascular Surgery, Korgialenio-Benakio Hellenic Red Cross Hospital, Athens, GRC
| | - Sofia Tzamtzidou
- Department of Vascular Surgery, Korgialenio-Benakio Hellenic Red Cross Hospital, Athens, GRC
| | - Dimitra Manou
- Department of Vascular Surgery, Korgialenio-Benakio Hellenic Red Cross Hospital, Athens, GRC
| | - Theofanis Papas
- Department of Vascular Surgery, Korgialenio-Benakio Hellenic Red Cross Hospital, Athens, GRC
| |
Collapse
|
4
|
Mesnard T, Pruvot L, Oliver Patterson B, Préville AD, Azzaoui R, Sobocinski J. Early Institutional Experience with One-Piece Bifurcated-Fenestrated Stentgraft in the Treatment of Abdominal Aortic Aneurysms. J Endovasc Ther 2024; 31:241-247. [PMID: 36112831 DOI: 10.1177/15266028221119612] [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] [Indexed: 02/18/2024]
Abstract
PURPOSE To review the early experience of the use of a bifurcated-fenestrated endograft (Bif-FEVAR) to treat abdominal aortic aneurysms (AAA) in a high-volume aortic center. METHODS A retrospective single-center analysis was conducted between March 2019 and April 2021 including consecutive patients that underwent Bif-FEVAR. Only patients without a proper infrarenal neck and a distance <70 mm between the lowest target artery and the native or prosthetic aortic bifurcation were considered. All Bif-FEVAR custom-made devices were manufactured by Cook Medical (Inc., Bloomington, Indiana). Demographics, anatomical features, technical success, major adverse events, 30-day mortality, and survival according to Kaplan-Meier were analyzed according to Society for Vascular Surgery standards. RESULTS Overall, 10 patients (100% male with median age 78) were included. The median preoperative maximal aneurysm diameter was 68 mm [51-84]. Eight patients were treated for a proximal type I endoleak after endovascular aneurysm repair. A total of 36 fenestrations were planned. The median operative time was 144 min [127-168], with a median fluoro time of 40.5 min [34-54] and a median dose area product of 73 Gy cm2 [61-89]. Technical success rate was 100%. No patients experienced a major postoperative adverse event. Median follow-up time was 8 months [6-13]. CONCLUSION Bif-FEVAR is technically feasible when there is a short distance below the lowest target artery and the aortic bifurcation, with favorable short-term results. CLINICAL IMPACT This study assessed the use of an innovative one-piece bifurcated fenestrated stent-graft as a primary procedure or in the treatment of proximal endoleak after standard infrarenal EVAR. We demonstrated these custom-made devices can be used safely with favorable short-term results. One-piece bifurcated fenestrated stent-grafts extend the indications of FEVAR for patients with an unusually short distance between the lowest renal artery and the aorto-iliac bifurcation or the diverter flow of a preexisting bifurcated infrarenal stent-graft.
Collapse
Affiliation(s)
- Thomas Mesnard
- Service de chirurgie vasculaire, Centre de l'Aorte, CHU Lille, Université de Lille, Lille, France
- U1008 - Controlled Drug Delivery Systems and Biomaterials, CHU Lille, Université de Lille, Lille, France
| | - Louis Pruvot
- Service de chirurgie vasculaire, Centre de l'Aorte, CHU Lille, Université de Lille, Lille, France
| | | | - Agathe De Préville
- Service de chirurgie vasculaire, Centre de l'Aorte, CHU Lille, Université de Lille, Lille, France
| | - Richard Azzaoui
- Service de chirurgie vasculaire, Centre de l'Aorte, CHU Lille, Université de Lille, Lille, France
| | - Jonathan Sobocinski
- Service de chirurgie vasculaire, Centre de l'Aorte, CHU Lille, Université de Lille, Lille, France
- U1008 - Controlled Drug Delivery Systems and Biomaterials, CHU Lille, Université de Lille, Lille, France
| |
Collapse
|
5
|
Alqahtani SS, Aljaber FK, Alsuwailem BY, AlMashouq YA, Alharbi BG, Masoud RH, Albaqami FA. Open Surgical Conversion After Endovascular Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e57271. [PMID: 38686244 PMCID: PMC11056809 DOI: 10.7759/cureus.57271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2024] [Indexed: 05/02/2024] Open
Abstract
Endovascular aneurysm repair (EVAR) is a preferred treatment for abdominal aortic aneurysms, though it comes with complications such as endoleaks and graft infections that may necessitate late open conversion (LOC). This systematic review and meta-analysis, drawing on studies from PubMed/MEDLINE, Embase, and the Cochrane Database of Systematic Reviews, aimed to evaluate the incidence, outcomes, and factors leading to LOC after EVAR. The analysis of 11 selected studies revealed a 5.3% incidence of LOC, with a patient cohort predominantly male (79%) and an average age of 73.5 years. The interval between initial EVAR and LOC was 35.1 months on average, with the Excluder device most frequently necessitating LOC. A notable 68% of endovascular salvage attempts before LOC failed. The study highlighted rupture and type I endoleak as the primary reasons for urgent LOC, which exhibited a 10-fold higher mortality rate compared to elective LOC. Elective LOC procedures had a 30-day mortality rate similar to primary elective open aneurysm repairs. These findings underscore the importance of vigilant post-EVAR patient monitoring and suggest that the methodological quality of underlying research should be considered in interpreting these results.
Collapse
Affiliation(s)
| | - Fahad K Aljaber
- Vascular Surgery, Prince Sultan Military Medical City, Riyadh, SAU
| | - Bader Y Alsuwailem
- Vascular Surgery, Prince Sultan Military Medical City, Riyadh, SAU
- Vascular Surgery, King Fahad Medical City, Riyadh, SAU
| | | | - Bander G Alharbi
- Vascular Surgery, Prince Sultan Military Medical City, Riyadh, SAU
- Vascular Surgery, Samsung Medical Center, Seoul, KOR
| | - Riyadh H Masoud
- Vascular Surgery, Prince Sultan Military Medical City, Riyadh, SAU
| | | |
Collapse
|
6
|
Esposito D, Rawashdeh M, Onida S, Turner B, Machin M, Pulli R, Davies AH. Systematic Review and Meta-Analysis of Elective Open Conversion versus Fenestrated and Branched Endovascular Repair for Previous Non-Infected Failed Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2024; 67:393-405. [PMID: 37748552 DOI: 10.1016/j.ejvs.2023.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE To evaluate outcomes of patients electively undergoing fenestrated and branched endovascular repair (F/B-EVAR) or open conversion for failed previous non-infected endovascular aneurysm repair (EVAR). DATA SOURCES Embase, MEDLINE, Cochrane Library. REVIEW METHOD The protocol was prospectively registered on PROSPERO (CRD42023404091). The review followed the PRISMA guidelines; certainty was assessed through the GRADE and quality through MINORS tools. Outcomes data were pooled separately for F/B-EVAR and open conversion. A random effects meta-analysis of proportions was conducted; heterogeneity was assessed with the I2 statistic. RESULTS Thirty eight studies were included, for a total of 1 645 patients of whom 1 001 (60.9%) underwent an open conversion and 644 (39.1%) a F/B-EVAR. The quality of evidence was generally limited. GRADE certainty was judged low for 30 day death (in both groups) and F/B-EVAR technical success, and very low for the other outcomes. Pooled 30 day death was 2.3% (I2 33%) in the open conversion group and 2.4% (I2 0%) in the F/B-EVAR conversion group (p = .36). Technical success for F/B-EVAR was 94.1% (I2 23%). The pooled 30 day major systemic complications rate was higher in the open conversion (21.3%; I2 74%) than in the F/B-EVAR (15.7%; I2 78%) group (p = .52). At 18 months follow up, the pooled re-intervention rate was 4.5% (I2 58%) in the open conversion and 26% (I2 0%) in the F/B-EVAR group (p < .001), and overall survival was 92.5% (I2 59%) and 81.6% (I2 68%), respectively (p = .005). CONCLUSION In the elective setting, and excluding infections, the early results of both open conversion and F/B-EVAR after failed EVAR appear satisfactory. Although open conversion presented with higher complication rates in the first 30 days after surgery, at follow up it seemed to be associated with fewer re-interventions and better survival compared with F/B-EVAR.
Collapse
Affiliation(s)
- Davide Esposito
- Department of Cardiothoracic and Vascular Surgery, Careggi University Hospital, Florence, Italy; Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Majd Rawashdeh
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sarah Onida
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Benedict Turner
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Matthew Machin
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Raffaele Pulli
- Department of Cardiothoracic and Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Alun H Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| |
Collapse
|
7
|
Elbayoumi EH, Farres H, Erben Y. Open Repair of a Large Abdominal Aortic Aneurysm With a Type 2 Endoleak After an Endovascular Aortic Aneurysm Repair: A Case Report and Literature Review. Cureus 2023; 15:e40315. [PMID: 37448430 PMCID: PMC10337833 DOI: 10.7759/cureus.40315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/01/2023] [Indexed: 07/15/2023] Open
Abstract
A type 2 endoleak (T2E) can occur after an endovascular aortic aneurysm repair (EVAR). The repair of a T2E is recommended after a sac enlargement of ≥5mm. We present a unique case of a 10 cm aneurysm sac that underwent open explantation 11 years after the initial EVAR and after having undergone several interventions to address the T2E.
Collapse
Affiliation(s)
- Eman H Elbayoumi
- Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, USA
| | - Houssam Farres
- Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, USA
| | - Young Erben
- Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, USA
| |
Collapse
|
8
|
Nana P, Kölbel T, Behrendt CA, Kouvelos G, Giannoukas A, Haulon S, Spanos K. Systematic review of reintervention with fenestrated or branched devices after failed previous endovascular aortic aneurysm repair. J Vasc Surg 2023; 77:1806-1814.e2. [PMID: 36375726 DOI: 10.1016/j.jvs.2022.11.037] [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: 08/10/2022] [Revised: 09/27/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND A proximal seal extension, after previously failed standard endovascular abdominal aortic aneurysm repair (EVAR), has been described using various endovascular techniques. The aim of the present systematic review was to assess the technical success, 30-day mortality, and mortality and reintervention rates during the available follow-up for patients managed with endovascular methods after failed endovascular repair. METHODS The present systematic review followed the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement and was preregistered at PROSPERO (no. CRD42022350436). A search of the English literature, via Ovid, using the MEDLINE, EMBASE, and CENTRAL databases, until June 15, 2022, was performed. Observational studies (2000-2022) and case series with at least five patients who had undergone fenestrated/branched EVAR (F/BEVAR) after failed EVAR were considered eligible. Technical success and mortality at 30 days and the mortality and reintervention rates during available follow-up had to have been reported. The Newcastle-Ottawa scale was used to assess the risk of bias. The primary outcome was technical success and mortality at 30 days. RESULTS The initial search yielded 2558 reports. Ten studies were considered eligible, two of which were prospective. A total of 423 patients had undergone F/BEVAR after failed EVAR. The indication for reintervention was the presence of a type Ia endoleak in 44.9%. Technical success was reported in seven studies, and 319 of 336 interventions were considered successful (94.9%), according to each study's criteria. Of the 423 patients, 10 had died within 30 days (2.4%). Seven patients had presented with spinal cord ischemia (2.4%). Twenty-three acute kidney injury events were reported (6.8%). The mean follow-up was 18 months (range, 1-77 months). During follow-up, 47 deaths were reported (14.8%). Finally, 50 reinterventions of 303 procedures (16.5%) had been performed. CONCLUSIONS According to the available literature, F/BEVAR after failed EVAR can be performed with high technical success and low mortality during the perioperative period. The midterm mortality and reintervention rates were acceptable. However, further data are needed to provide firm conclusions regarding the safety and durability of F/BEVAR after failed EVAR.
Collapse
Affiliation(s)
- Petroula Nana
- Aortic Center, Marie Lannelongue Hospital, Le Plessis-Robinson, Paris Saclay University, Paris, France.
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - Christian-Alexander Behrendt
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | - George Kouvelos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Athanasios Giannoukas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Stephan Haulon
- Aortic Center, Marie Lannelongue Hospital, Le Plessis-Robinson, Paris Saclay University, Paris, France
| | - Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany; Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| |
Collapse
|
9
|
Ozawa H, Ohki T, Shukuzawa K, Chono Y, Omori M, Baba T, Hara M, Tachihara H. Evolution of open aneurysmorrhaphy for management of sac expansion after endovascular repair of abdominal aortic aneurysms. J Vasc Surg 2023; 77:760-768. [PMID: 36306936 DOI: 10.1016/j.jvs.2022.10.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE We evaluated the perioperative and mid-term clinical outcomes of open aneurysmorrhaphy (OA) for the treatment of sac expansion after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms. METHODS OA involves sac exposure without dissection of the proximal or distal neck, sacotomy and ligation of back-bleeding vessels, preservation of the prior stent graft, and tight closure of the sac around the stent graft. We performed a retrospective review of all patients who had undergone OA for nonruptured sac expansion after standard EVAR at our institution between January 2015 and June 2021. The primary end points were 30-day mortality and aneurysm-related death. The secondary end points were postoperative complications, overall survival, freedom from reintervention, and sac regrowth rate. RESULTS A total of 28 patients had undergone OA. Their mean age was 76.9 ± 6.7 years. The median sac diameter at OA was 79 mm (interquartile range [IQR], 76-92 mm). The median duration from the index EVAR to OA was 82 months (IQR, 72-104 months). Preoperative computed tomography angiography confirmed a type II endoleak (EL) in 20 patients, 1 of whom had had a coexisting type Ia EL; a type IIIb EL was identified in 1 patient. Concomitant endovascular procedures had been performed in six patients to treat a type I or III EL or reinforce the proximal and distal seals. The OA technique has been modified since 2017, with the addition of more aggressive dissection of the sac and complete removal of the mural thrombus to further decrease the sac diameter. Postoperative complications occurred in two patients and included abdominal lymphorrhea and failed hemostasis of the common femoral artery requiring surgical repair in one patient each. The 30-day mortality was 0%. During the median follow-up of 36 months (IQR, 14-51 months), the overall survival was 92.7% and 86.9% at 12 and 36 months, respectively, without any aneurysm-related death. In the late (2017-2021) treatment group, the median sac diameter immediately after OA was smaller than that in the early (2015-2016) treatment group (early group: median, 50 mm; IQR, 39-57 mm; vs later group: median, 41 mm; IQR, 32-47 mm; P = .083). Furthermore, in the late group, the sac regrowth rate was lower (early group: median, 0.36 mm/mo; IQR, 0.23-0.83 mm/mo; vs late group: median, 0 mm/mo; IQR, 0-0.11 mm/mo; P = .0075) and the freedom from reintervention rate was higher (late group: 94.7% at both 12 and 36 months, respectively; early group: 71.4% and 53.6% at 12 and 36 months, respectively; log-rank P = .070). CONCLUSIONS Our results have shown that OA for the management of post-EVAR sac expansion is feasible with acceptable mid-term outcomes. Aggressive dissection and tight plication of the sac might be imperative for better mid-term outcomes after OA.
Collapse
Affiliation(s)
- Hirotsugu Ozawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Kota Shukuzawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiko Chono
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Makiko Omori
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takeshi Baba
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masayuki Hara
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiromasa Tachihara
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
10
|
Sen I, Kanzafarova I, Yonkus J, Mendes BC, Colglazier JJ, Shuja F, DeMartino RR, Kalra M, Rasmussen TE. Clinical presentation, operative management, and long-term outcomes of rupture after previous abdominal aortic aneurysm repair. J Vasc Surg 2023; 77:396-405.e7. [PMID: 36272507 DOI: 10.1016/j.jvs.2022.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/30/2022] [Accepted: 08/08/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate the presentation trends, intervention, and survival of patients who had been treated for late abdominal aortic aneurysm rupture (LAR) after open repair (OR) or endovascular aortic aneurysm repair (EVAR). METHODS We reviewed the clinical data from a single-center, retrospective database for patients treated for LAR from 2000 to 2020. The end points were the 30-day mortality, major postoperative complication, and survival. The outcomes between LAR managed with EVAR (group I) vs OR were compared (group II). RESULTS Of 390 patients with infrarenal aortic rupture, 40 (10%) had experienced aortic rupture after prior aortic repair and comprised the LAR cohort (34 men; age 78 ± 8 years). LAR had occurred before EVAR in 30 and before OR in 10 patients. LAR was more common in the second half of the study with 32 patients after 2010. LAR after prior OR was secondary to ruptured para-anastomotic pseudoaneurysms. After initial EVAR, LAR had occurred despite reintervention in 17 patients (42%). The time to LAR was shorter after prior EVAR than after OR (6 ± 4 vs 12 ± 4 years, respectively; P = .003). Treatment for LAR was EVAR for 25 patients (63%; group I) and OR for 15 (37%, group II). LAR after initial OR was managed with endovascular salvage for 8 of 10 patients. Endovascular management was more frequent in the latter half of the study period. In group I, fenestrated repair had been used for seven patients (28%). Salvage for the remaining cases was feasible with EVAR, aortic cuffs, or limb extensions. The incidence of free rupture, time to treatment, 30-day mortality (8% vs 13%; P = .3), complications (32% vs 60%; P = .1), and disposition were similar between the two groups. Those in group I had had less blood loss (660 vs 3000 mL; P < .001) and less need for dialysis (0% vs 33%; P < .001) than those in group II. The median follow-up was 21 months (interquartile range, 6-45 months). The overall 1-, 3-, and 5-year survival was 76%, 52%, and 41%, respectively, and was similar between groups (28 vs 22 months; P = .48). Late mortality was not related to the aorta. CONCLUSIONS LAR after abdominal aortic aneurysm repair has been encountered more frequently in clinical practice, likely driven by the frequency of EVAR. However, most LARs, including those after previous OR, can now be salvaged with endovascular techniques with lower morbidity and mortality.
Collapse
Affiliation(s)
- Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
| | - Irina Kanzafarova
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jennifer Yonkus
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Todd E Rasmussen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
11
|
Sultan S, Acharya Y, Hezima M, Chua Vi Long K, Soliman O, Parodi J, Hynes N. Two decades of experience in explantation and graft preserving strategies following primary endovascular aneurysm repair and lessons learned. Front Surg 2022; 9:963172. [PMID: 36570807 PMCID: PMC9774497 DOI: 10.3389/fsurg.2022.963172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/26/2022] [Indexed: 12/13/2022] Open
Abstract
Objectives We aim to scrutinize our evolving re-intervention strategies following primary endovascular aortic aneurysm repair (EVAR) - EVAR GORE SalvAge Fabric Technique (ARAFAT), aortic sac double breasting with endograft preservation, and stent-graft explantation. Methods We performed 1,555 aortic interventions over the study period, including 910 EVARs. Factors associated with the need for reintervention and the likelihood of chronic fabric fatigue failure (CFFF) were investigated. Using conventional and innovative diagnostic modalities with Prone contrASt enHanced computed tomography Angiography (PASHA), 136 endoleaks (ELs) were identified (15 type I, 98 type II; 18 type III; 5 type IV). Results Forty-four (4.84%) patients underwent re-intervention post-primary EVAR; 18 ARAFATs, 12 double breastings, and 14 explantations. Choice of re-intervention was based on patient fitness and mode of failure. Mean EL detection duration following primary EVAR was 53.3 ± 6.82 months, while mean time to re-intervention was 70.20 ± 6.98 months. The mean sac size before the primary EVAR and re-intervention was 6.00 ± 1.75 cm and 7.51 ± 1.94 cm, respectively. Polyester (61.40%) was the most commonly employed stent-graft material. Use of more than three modular stent-graft components (3.42 ± 1.31, p = 0.846); with the proximal stent-graft diameter of 31.6 ± 3.80 cm (p = 0.651) and the use of iliac limbs more than 17 mm (p = 0.364), all added together are contributing factors. We had one peri-operative mortality following explantation due to sepsis-induced multiorgan failure. Conclusions Our re-intervention strategies matured from stent graft explantation to graft preservation with endovascular relining of the stent-graft. Graft preservation with aortic sacotomy and double breasting were used to manage concealed ELs due to aortic hygroma.
Collapse
Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland,Galway: Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and National University of Ireland, Galway affiliated Hospital, Galway, Ireland,CORRIB-CURAM-Vascular Group, National University of Ireland, Galway, Ireland,Correspondence: Sherif Sultan ,
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland,Galway: Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and National University of Ireland, Galway affiliated Hospital, Galway, Ireland
| | - Mohieldin Hezima
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Keegan Chua Vi Long
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Osama Soliman
- CORRIB-CURAM-Vascular Group, National University of Ireland, Galway, Ireland
| | - Juan Parodi
- Department of Vascular Surgery and Biomedical Engineering Department, Alma mater, University of Buenos Aires, and Trinidad Hospital, Buenos Aires, Argentina,Winston-Salem and St. Louis: Wake Forest University, Winston-Salem, North Carolina and Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Niamh Hynes
- CORRIB-CURAM-Vascular Group, National University of Ireland, Galway, Ireland
| |
Collapse
|
12
|
de Boer M, Qasabian R, Dubenec S, Shiraev T. The failing endograft-A systematic review of aortic graft explants and associated outcomes. Vascular 2022:17085381221082370. [PMID: 35451910 DOI: 10.1177/17085381221082370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The prominent use of endovascular stent grafts in the management of abdominal aortic aneurysms is associated with increased descriptions of late complications such as graft infection and endoleaks, which can confer significant morbidity and mortality. Failed endovascular management of late complications often requires open conversion and graft explantation. This systematic review sought to highlight the peri- and post-operative course of patients undergoing aortic graft explants to inform readers of the associated morbidity and mortality of patients undergoing this procedure. METHODS The review was conducted in accordance with PRISMA guidelines. A search of the PubMed, Google Scholar and Ovid MEDLINE databases from January 1995 to April 2021 was performed with a combination of MeSH terms pertaining to endovascular aneurysm repair and open conversion. Articles were screened and included based on pre-determined selection criteria. RESULTS A total of 818 studies were identified, with 41 meeting inclusion criteria. These studies examined a total of 1324 patients, 84.3% of whom were male with a mean age of 74 years at explantation. Mean time to graft explantation was 36 months, with a mean aneurysm size of 66 mm. The majority of aortic explants were performed for persistent endoleaks (68%), and 10% for infection. There was high morbidity with the procedure, with high rates of post-operative complications (mean, 37%) and 30-day mortality (11%). The most common complications included renal (15%), respiratory (12%) and cardiac (9%). Most explanted grafts were first-generation endografts. Morbidity and mortality rates were reduced in patients undergoing elective explants compared to emergent procedures (3.3% compared to 43.4%). CONCLUSION Aortic graft explant remains a highly co-morbid procedure, with high rates of peri- and post-operative complications and mortality. The number of explant procedures reported over the past 25 years has increased, reflecting the prominent use of EVAR in the management of AAAs. Whilst remaining a highly co-morbid procedure, patients undergoing elective explants had markedly reduced rates of mortality and morbidity compared to emergent explants. Thus, clinical focus should be on identifying patients who require graft explantation early to perform these procedures in an elective setting.
Collapse
Affiliation(s)
- Madeleine de Boer
- Department of Vascular Surgery, RinggoldID:2205Royal Prince Alfred Hospital, Camperdown, NSW, AU
| | - Raffi Qasabian
- Department of Vascular Surgery, RinggoldID:2205Royal Prince Alfred Hospital, Camperdown, NSW, AU
| | - Steven Dubenec
- Department of Vascular Surgery, RinggoldID:2205Royal Prince Alfred Hospital, Camperdown, NSW, AU
| | - Timothy Shiraev
- Department of Vascular Surgery, RinggoldID:2205Royal Prince Alfred Hospital, Camperdown, NSW, AU.,School of Medicine, The University of Notre Dame, Darlinghurst, NSW, AU
| |
Collapse
|
13
|
Nana P, Spanos K, Kouvelos G, Stamoulis K, Rountas C, Arnaoutoglou E, Matsagkas M, Giannoukas AD. Ten-year single center experience in elective standard endovascular abdominal aortic aneurysm repair. INT ANGIOL 2021; 40:240-247. [PMID: 33739077 DOI: 10.23736/s0392-9590.21.04648-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) has become the treatment of choice for abdominal aortic aneurysm (AAA), demonstrating excellent early outcomes. However, EVAR durability has been questioned in the long-term period. The aim of this study was to assess EVAR outcomes in terms of survival and freedom from re-intervention during a long-term period. METHODS All consecutive patients being treated, with elective standard EVAR, in a single tertiary center, were included between 2008 and 2018. Outcomes were defined as survival and freedom from re-intervention and were reported using Kaplan-Meyer lifetables. In subgroup analyses, sex, age (threshold at 65 and 80 years), neck diameter>28mm and type of fixation were also analyzed. Type of re-intervention and endoleak type I (ETIa) were also reported. RESULTS Five hundred and eight patients (94% males, mean age 72±7.3, mean AAA diameter 59±9mm) were included. The median follow-up was 3 years (range 0-10 years). The survival rate was 92.8% (SE 1.5%), 76.5% (SE 3.1%) and 41.6% (SE 6%), at 2, 5 and 10 years of follow-up, respectively. In total, 78 patients died; 8 deaths (8/75, 10%) were aneurysm related. In multivariate regression analysis, age (CI. 1.02-1.14; p=0.006) and ever tobacco use (CI. 1.02-6.12, P=0.045) were associated with the long-term mortality. Freedom from re-intervention was 96% (SE 1.1%), 93% (SE 1.8%), 85.5% (SE 5%) at 2, 5 and 9 years of follow-up. Limb occlusion was a common complication (n/n; 30% of re-intervention), particularly within the first 2 postoperative years. Six patients presented with rupture and were treated with open conversion. EVAR cases with supra-renal fixation graft presented lower rates of ETIa (CI. 76-87.27, P<0.001). CONCLUSIONS Elective standard EVAR is associated with good long-term survival showing low aneurysm-related mortality. Common risk factors such as advanced age and smoking are associated to higher mortality. The procedure presents low re-intervention rates, while limb occlusion is a complication presented within the first 2 postoperative years.
Collapse
Affiliation(s)
- Petroula Nana
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece -
| | - Konstantinos Spanos
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - George Kouvelos
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Konstantinos Stamoulis
- School of Health Sciences, Department of Anesthesiology, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Christos Rountas
- School of Health Sciences, Department of Radiology, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Elena Arnaoutoglou
- School of Health Sciences, Department of Anesthesiology, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Miltiadis Matsagkas
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Athanasios D Giannoukas
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| |
Collapse
|
14
|
Aortoduodenal fistulas after endovascular abdominal aortic aneurysm repair and open aortic repair. J Vasc Surg 2021; 74:711-719.e1. [PMID: 33684467 DOI: 10.1016/j.jvs.2021.02.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 02/11/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE In the present study, we have reported and compared aortoduodenal fistulas (ADFs) after endovascular abdominal aortic aneurysm repair (EVAR) vs after open aortic repair (OAR). METHODS We retrospectively analyzed the data from patients treated for ADFs from January 2015 to May 2020 in our hospital. The clinical data, diagnostic procedures, and surgical options were evaluated. The primary endpoints of the present study were 30-day and 1-year mortality. The secondary endpoints were major postoperative complications. RESULTS A total of 24 patients (20 men; median age, 69 years; range, 53-82 years) were admitted with ADFs after EVAR (n = 9) or OAR (n = 15). These patients accounted for ∼4.3% of all abdominal aortic aneurysm repairs in our hospital. The median interval from the initial aortic repair and the diagnosis of ADF was 68 months (range, 6-83 months) for the ADF-EVAR group and 80 months (range, 1-479 months) for the ADF-OAR group. Three patients in the ADF-EVAR group had refused surgical treatment owing to their high surgical risk. One patient in the ADF-OAR group had undergone removal of the aortic prosthesis without replacement. Of the remaining 20 patients, 12 (ADF-EVAR group, n = 4; ADF-OAR group, n = 8) had undergone in situ replacement of the aorta and 8 (ADF-EVAR group, n = 2; ADF-OAR group, n = 6) had undergone extra-anatomic reconstruction with aortic ligation. After a mean follow-up of 26 months, no patient had experienced early limb loss. However, one case of rupture of the venous graft (ADF-EVAR), one case of aortic stump blowout (ADF-OAR), and one case of a ureteroarterial fistula with a homograft (ADF-OAR) had occurred. Overall, the incidence of postoperative complications was significantly greater after ADF-OAR (93% vs 33%; P = .036). The most frequent bacteria involved in the blood cultures were Escherichia coli (25% of patients), and Candida spp. (61%) were the predominant pathogens found on intra-abdominal smears. The in-hospital mortality rates for the ADF-EVAR and ADF-OAR group were 22% and 13%, respectively. The corresponding 1 -year mortality rates were 22% and 33%. CONCLUSIONS Patients with ADFs after EVAR or OAR have limited overall survival. In addition to the similar therapeutic approaches, we found no significant differences in postoperative mortality between these two uncommon pathologic entities. In our study, the overall postoperative morbidity seemed greater for the ADF-OAR group.
Collapse
|
15
|
Bellamkonda K, Ochoa Chaar CI. Open repair of type III endoleak with preservation of the endograft for a ruptured abdominal aortic aneurysm after endovascular aneurysm repair. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 7:117-119. [PMID: 33718680 PMCID: PMC7921175 DOI: 10.1016/j.jvscit.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/10/2020] [Indexed: 10/28/2022]
Abstract
Abdominal aortic aneurysm rupture after endovascular aneurysm repair (EVAR) is rare, but remains a significant limitation of endovascular technology. Preservation of the endograft during open conversion of a post-EVAR rupture has been shown to be associated with improved perioperative outcomes. An interposition Dacron graft with felt pledgets is a novel bail-out option for the open reconstruction of a type III endoleak with total endograft preservation. This technique is useful in high-risk patients presenting with ruptured abdominal aortic aneurysm after EVAR and no clear source of endoleak.
Collapse
Affiliation(s)
- Kirthi Bellamkonda
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, New Haven, Conn
| | | |
Collapse
|
16
|
Chung BH, Heo SH, Park YJ, Kim DI, Kim DK, Kim YW. Strategy to avoid open surgical conversion after endovascular aortic aneurysm repair for patients with infrarenal abdominal aortic aneurysm. Ann Surg Treat Res 2020; 99:344-351. [PMID: 33304862 PMCID: PMC7704275 DOI: 10.4174/astr.2020.99.6.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 08/11/2020] [Accepted: 09/17/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose Open surgical conversion (OSC) is the last treatment option for patients with endovascular aneurysm repair (EVAR)failure. We investigated the underlying causes of EVAR failure requiring OSC and attempted to determine strategies to avoid OSC after EVAR. Methods We retrospectively reviewed the database of patients who underwent OSC after EVAR from 2005 to 2018 in a single institution. Twenty-six OSCs were performed in 24 patients (median age, 74.5 years; 79.2% of males) who had undergone standard EVAR. We investigated pre-, intra-, and postoperative computed tomography or angiographic images and outcomes of the OSCs. Results Two main indications for OSC were persistent endoleak (50.0%) and endograft infection (EI) (38.5%). All 13 patients who underwent OSC due to endoleaks received EVAR outside of indications for use. Among 10 patients who underwent OSC due to EI, we found overlooked infection sources in 7 (70.0%) at the time of EVAR or during the surveillance period. OSC was performed at a median of 31.8 months (interquartile range, 9.4-69.8) after EVAR as an emergency (15.4%) or elective (84.6%) surgery. Aortic endograft was removed in 84.6% of cases (totally, 57.7%; partially, 26.9%), whereas it was preserved in 4 cases (15.4%). After 26 OSCs, 2 early deaths (7.7%) and 2 aortoenteric fistulae (7.7%) developed as major complications. Conclusion OSC after EVAR was associated with relatively higher perioperative morbidity and mortality. To avoid OSC after EVAR, we recommend careful assessment of coexisting infection sources and avoidance of EVAR for patients with especially unfavorable anatomy for EVAR, particularly the in proximal neck.
Collapse
Affiliation(s)
- Byeoung-Hoon Chung
- Department of Surgery, Jeonbuk National University Hospital, Jeonju, Korea
| | - Seon-Hee Heo
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Cardiac and Vascular Center, Samsung Medical Center, Seoul, Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Cardiac and Vascular Center, Samsung Medical Center, Seoul, Korea
| | - Dong-Ik Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Cardiac and Vascular Center, Samsung Medical Center, Seoul, Korea
| | - Duk-Kyoung Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Cardiac and Vascular Center, Samsung Medical Center, Seoul, Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Department of Surgery, Kangbuk Samsung Hospital, Seoul, Korea
| |
Collapse
|
17
|
Lin J, Nutley M, Li C, Douglas G, Du J, Zhang Z, Douville Y, Guidoin R, Wang L. Innovative textile structures designed to prevent type III endoleaks in endovascular stent-grafts. Artif Organs 2020; 45:278-288. [PMID: 32969519 DOI: 10.1111/aor.13819] [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: 06/20/2020] [Revised: 08/20/2020] [Accepted: 09/07/2020] [Indexed: 12/14/2022]
Abstract
The damage caused to the fabric of endovascular stent-grafts most often occurs at the contact zones between the fabrics where they are attached to the apices of Z-shaped stents as a result of normal physiologic pulsatile movement within angulated vessels in vivo. Although design improvements were made over the years, the risks were not fully eliminated even with the newer M-shaped stent reconfiguration. In this study, we proposed to create and manufacture a novel fabric for stent-grafts with specifically designed reinforced zones to enhance resistance to fabric abrasion. These reinforced zones are set at the vicinity of the apices of the Z-shaped stents and between two adjacent Z-shaped stents where folding and pleating are commonly observed to occur in angulated vessels. Three innovative weaving structures with two different types of yarns and two controls were designed and prepared. Two commonly used commercial devices supported, respectively, with ringed stents, and Z-shaped stents were selected as the references for comparison. Textile structures including thickness, water permeability, mechanical properties, (more specifically tensile and bursting stress, as well as fatigue simulation) were tested on all fabrics. Compared to commercially available plain weaves, the fabrics with locally reinforced zones showed improved mechanical characteristics and fatigue resistant properties. A fabric designed with specifically reinforced zones has now clearly been shown to effectively reduce the abrasion caused by the apices of Z-shaped stents. However, further optimization may still be possible.
Collapse
Affiliation(s)
- Jing Lin
- Key Laboratory of Textile Science and Technology of Ministry of Education, Donghua University, Shanghai, China
| | - Mark Nutley
- Division of Vascular Surgery and Department of Diagnostic Imaging, Peter Lougheed Centre, University of Calgary, Calgary, AB, Canada
| | - Chaojing Li
- Key Laboratory of Textile Science and Technology of Ministry of Education, Donghua University, Shanghai, China
| | - Graeham Douglas
- Department of Engineering, University of Cambridge, Cambridge, UK
| | - Jia Du
- Key Laboratory of Textile Science and Technology of Ministry of Education, Donghua University, Shanghai, China
| | - Ze Zhang
- Department of Surgery, Université Laval, Centre de Recherche du CHU de Québec - Université Laval, Quebec, QC, Canada
| | - Yvan Douville
- Department of Surgery, Université Laval, Centre de Recherche du CHU de Québec - Université Laval, Quebec, QC, Canada
| | - Robert Guidoin
- Department of Surgery, Université Laval, Centre de Recherche du CHU de Québec - Université Laval, Quebec, QC, Canada
| | - Lu Wang
- Key Laboratory of Textile Science and Technology of Ministry of Education, Donghua University, Shanghai, China
| |
Collapse
|
18
|
Lessons Learned from Open Surgical Conversion after Failed Previous EVAR. Ann Vasc Surg 2020; 71:356-369. [PMID: 32890649 DOI: 10.1016/j.avsg.2020.08.122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Delayed open conversion (OpC) after endovascular aortic aneurysm repair (EVAR) is becoming increasingly common worldwide. We reviewed our experience to characterize the perioperative spectrum of OpC repairs. MATERIALS AND METHODS A retrospective analysis of a prospectively maintained institutional database to identify patients who underwent late OpC after failed EVAR was performed. Patient and aneurysm baseline characteristics, mechanism of failure, perioperative details, including type of repair/complications/survival, and late outcomes were examined. RESULTS From January 2003 to January 2020, 38 male patients (mean age, 75 ± 7 years; range, 60-90) required late OpC. Interval time from initial EVAR to OpC was 63.6 ± 33.8 months (range, 17-120). Mean diameter of the aneurysms was 82.2 ± 22.1 mm before OpC compared with 62.9 ± 13 mm before endograft implantation. Mechanisms of failure were type Ia, Ib, II, and III endoleaks in 14 (36.8%), 9 (23.7%), 4 (10.5%), and 1 (2.6%) patient(s), respectively; infection in 3 (7.9%), leg ischemia in 2 (5.3%), and multiple causes in 5 (13.2%) patients. We observed 4 (10.5%) asymptomatic, 16 (42.1%) symptomatic, and 18 (47.3%) ruptured aneurysms. Four patients (10.5%) had stable contained ruptures, whereas the remaining 13 (34.2%) and 1 additional patient (2.6%) with aortoenteric fistula presented with hemorrhagic shock (class ≥II). Total endograft explantation, endograft preservation, or proximal/distal partial graft removal was performed in 16 (42.1%), 10 (26.3%), and 2 (5.2%)/9 (23.7%) of patients, respectively. Technical success was 100%, excluding an early postaortic clamping death. Overall, 30-day mortality was 21.1% (8 of 38) and significantly higher in patients with hemorrhagic shock or hemodynamic instability at presentation (P = 0.04 and P = 0.009, respectively) and in patients who had endografts with hooks/barbs or experiencing higher postoperative complication rate (P = 0.02 and P = 0.006, respectively). By definition, procedure success was 81.1%. Mean follow-up was 37.6 ± 39.8 months. By the end of the study, we recorded 11 deaths (2 were aneurysm related). CONCLUSIONS Despite high technical success, OpC has a significant mortality in patients presenting with hemorrhagic shock and had active fixation endografts or experiencing high complication rate. Many other confounding factors may play a role.
Collapse
|
19
|
Gonzalez-Urquijo M, Lozano-Balderas G, Fabiani MA. Type II Endoleaks After EVAR: A Literature Review of Current Concepts. Vasc Endovascular Surg 2020; 54:718-724. [PMID: 32744153 DOI: 10.1177/1538574420945448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Endoleak is the most frequent complication following endovascular aneurysm repair, which is not present in the surgical counterpart. The most frequent type of endoleak corresponds to type II, and its natural history remains poorly understood. Therefore, their treatment continues to be a topic of debate. The vast majority of the studies found in the literature are of a retrospective nature, and there are no prospective studies comparing intervention versus a conservative approach. Future studies should aim to compare not only different approaches to resolve type II endoleak but also when should be the right time to treat them, with the primary purpose of avoiding sac rupture. The objective of this review is to provide the reader with a literature overview about type II endoleaks to help in the decision-making process on this topic.
Collapse
Affiliation(s)
| | - Gerardo Lozano-Balderas
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo León, México
| | - Mario Alejandro Fabiani
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo León, México
| |
Collapse
|
20
|
Chastant R, Canaud L, Ozdemir BA, Aubas P, Molinari N, Picard E, Branchereau P, Marty-Ané CH, Alric P. Elective late open conversion after endovascular aneurysm repair is associated with comparable outcomes to primary open repair of abdominal aortic aneurysms. J Vasc Surg 2020; 73:502-509.e1. [PMID: 32473342 DOI: 10.1016/j.jvs.2020.05.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 05/06/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Three of four patients with infrarenal abdominal aortic aneurysm are now treated with endovascular aneurysm repair (EVAR). The incidence of secondary procedures and surgical conversions is increasing for a population theoretically unfit for open surgery. The indications and outcomes of late open surgical conversions after EVAR in a high-volume tertiary vascular unit are reported. METHODS This retrospective single-center study includes all patients who underwent a late open conversion between January 1996 and July 2018. Data were collected from records on patient demographics, operative indications, surgical strategy, perioperative outcomes, and medium-term survival. RESULTS Sixty-two consecutive patients (88.7% male) with a mean age of 77.5 years are included. The median duration since index EVAR was 38.5 months; 65% of stent grafts requiring late open conversion had suprarenal fixation. Indications included 22.6% type IA, 16.1% type IB, and 45.2% type II endoleaks; 12.9% graft thrombosis; and 14.5% endoprosthesis infection. Complete endograft explantation was performed in 37.1% of patients and a partial explantation in 54.8%, whereas 8.1% of stent grafts were wholly preserved in situ. Overall 30-day mortality was 12.9% (n = 8) in the cohort and 2.7% for elective patients. The all-cause morbidity rate was 40.1%, and the median length of hospital stay was 9 days. After follow-up of 28.4 months (range, 1.8-187.3 months), all-cause survival was 58.8%. Avoidance of aortic clamping (P = .006) and elective procedures (P = .019) were associated with a significant reduction in the length of hospital stay. Moreover, the 30-day mortality (P = .002), occurrence of postoperative renal dysfunction (P = .004), and intestinal ischemia (P = .017) were increased in the emergency setting. Excluding cases with rupture or infection, survival estimates were 97%, 97%, and 71% at 1 year, 2 years, and 5 years, respectively. CONCLUSIONS Technically more complex than primary open surgery, late open conversion is a procedure that generates an acceptable perioperative risk when it is performed in a high-volume aortic surgical center. Elective open conversion is associated with excellent early and late outcomes. Endograft preservation strategies decrease perioperative morbidity.
Collapse
Affiliation(s)
- Robin Chastant
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.
| | - Ludovic Canaud
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Baris Ata Ozdemir
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France; Vascular and Endovascular Department, North Bristol NHS Trust and University of Bristol, Bristol, United Kingdom
| | - Pierre Aubas
- Department of Medical Information, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Nicolas Molinari
- Department of Medical Information, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Eric Picard
- Department of Vascular and Thoracic Surgery, Caremeau Hospital, Nimes, France
| | - Pascal Branchereau
- Department of Vascular and Thoracic Surgery, Caremeau Hospital, Nimes, France
| | - Charles-Henri Marty-Ané
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Pierre Alric
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| |
Collapse
|
21
|
Väärämäki S, Salenius J, Pimenoff G, Uurto I, Suominen V. Overall outcome after endovascular aneurysm repair with a first-generation stent graft (Vanguard): A 20-year single-center experience. J Vasc Surg 2020; 72:896-903. [PMID: 32139310 DOI: 10.1016/j.jvs.2019.11.027] [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: 07/18/2019] [Accepted: 11/03/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The problems with first-generation stent grafts for endovascular aneurysm repair are well known, but their long-term outcome remains to be established. The purpose of the study was to characterize the outcome of patients treated for abdominal aortic aneurysm (AAA) with a first-generation stent graft, Vanguard (Boston Scientific, Natick, Mass), in a single academic center with a follow-up of up to 20 years. METHODS There were 48 AAA patients electively treated with a Vanguard stent graft between February 1997 and November 1999. The patients were monitored annually until the end of 2018. The outcomes were overall survival and the number of graft-related complications and reinterventions. RESULTS The mean age was 70 years (range, 54-85 years), and the mean follow-up was 107 months (range, 6-262 months). All stent grafts were successfully implanted, but 90% of the patients encountered graft-related complications during follow-up. The most common complications were endoleaks (type I, 27%; type II, 29%; type III, 31%), stent fracture (46%), graft thrombosis (31%), and migration (40%). A total of 40 (83%) patients required a secondary procedure during long-term follow-up. The endovascular method for treating the complication was successful in 73 (87%) of 84 cases. There were no primary conversions, but 10 patients (21%) required a late conversion. In five cases, the complications required relining with a newer device. There were four AAA ruptures (8.3%), two of them fatal. The cumulative overall survival rates were 94%, 69%, 33%, 15%, and 13% at 1 year, 5 years, 10 years, 15 years, and 20 years, respectively. CONCLUSIONS The use of the Vanguard, a first-generation stent graft, was associated with multiple graft-related complications. However, these complications could mainly be treated by endovascular means. The Vanguard stent graft is a good example of how new technology can cause unpredictable problems that can magnify the workload and endanger the patient's well-being even decades after the initial procedure.
Collapse
Affiliation(s)
- Suvi Väärämäki
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland.
| | - Juha Salenius
- Division of Vascular Surgery, Department of Surgery, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Georg Pimenoff
- Division of Interventional Radiology, Department of Radiology, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Ilkka Uurto
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Velipekka Suominen
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital and University of Tampere, Faculty of Medicine and Life Sciences, Tampere, Finland
| |
Collapse
|
22
|
Davidovic LB, Palombo D, Treska V, Sladojevic M, Koncar IB, Houdek K, Spinella G, Zlatanovic P, Pane B. Late open conversion after endovascular abdominal aortic aneurysm repair: experience of three-high volume centers. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:183-190. [DOI: 10.23736/s0021-9509.19.10972-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
23
|
Acute aortic thrombosis in long-term after endovascular aneurysm repair: A case report. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 27:576-579. [PMID: 32082929 DOI: 10.5606/tgkdc.dergisi.2019.18001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 07/16/2019] [Indexed: 11/21/2022]
Abstract
Acute aortic thrombosis which develops in the longterm following an endovascular aneurysm repair is rare. A 78-year-old male patient presented with rest pain and sudden-onset coldness at lower limbs for four hours. His medical history revealed an endovascular aneurysm repair for an infrarenal abdominal aortic aneurysm two years ago. He was diagnosed with acute ischemia at lower limbs due to acute thrombosis of the infrarenal aorta. We first performed an axillobifemoral bypass surgery for limb salvage. Due to recurrent thromboses of the left limb of the graft during longterm follow-up, we applied aortobifemoral bypass procedure to provide adequate lower limb flow.
Collapse
|
24
|
D'Oria M, Mastrorilli D, Ziani B. Natural History, Diagnosis, and Management of Type II Endoleaks after Endovascular Aortic Repair: Review and Update. Ann Vasc Surg 2020; 62:420-431. [PMID: 31376537 DOI: 10.1016/j.avsg.2019.04.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/02/2019] [Accepted: 04/28/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Mayo Clinic Gonda Vascular Center, Rochester, MN; Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy.
| | - Davide Mastrorilli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Barbara Ziani
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| |
Collapse
|
25
|
Manunga J, Stanberry LI, Alden P, Alexander J, Skeik N, Stephenson E, Titus J, Karam J, Teng X, Sullivan T. Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts. CVIR Endovasc 2019; 2:34. [PMID: 32026021 PMCID: PMC6966416 DOI: 10.1186/s42155-019-0075-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 09/26/2019] [Indexed: 11/22/2022] Open
Abstract
Background Endovascular rescue of failed infrarenal repair (EVAR) has emerged as an attractive option to stent graft explantation. The procedure, however, is underutilized due to limited devices accessibility and the challenges associated with their implantation in this patient population. The purpose of this study was to report our outcomes and discuss our approach to rescuing previously failed infrarenal endovascular aneurysm repairs (EVAR) with fenestrated/branched endografts (f/b-EVAR). Methods A retrospective analysis of prospectively collected data of consecutive patients with failed EVAR rescued with f/b-EVAR at our institution from November 2013 to March 2019 was conducted. The study primary end point was technical success; defined as the implantation of the device with no type I a/b or type III endoleak or conversion to open repair. Secondary endpoints included major adverse events (MAEs), graft patency and reintervention rates. Results During this time, 202 patients with complex aortic aneurysms were treated with f/b-EVAR. Of these, 19 patients (Male: 17, mean age 79 ± 7 years) underwent repair for failed EVAR. The median time from failed repair to f/b-EVAR was 48 (30, 60) months. Treatment failure was attributed to stent graft migration in 9 (47.4%) patients, disease progression in 5 (26.3%), short initial neck in 3 (15.8%) and unable to be determined in 2 (10.5%). Three patients were treated urgently with surgeon modified stent graft. Technical success was achieved in 18 patients (95%), including two who had undergone emergent repair for rupture. Seventy-two targeted vessels (97.3%) were successfully incorporated. Sixteen (84.2%) patients required a thoracoabdominal repair to achieve a durable seal. Major adverse events (MAEs) occurred in 3 patients (15.7%) including paralysis and death in one (5.3%), compartment syndrome and temporary dialysis in another and laparotomy with snorkeling of one renal and bypass of the other in the third patient. Median (IQR) hospital length of stay was 3 (2, 4) days. Late reintervention, primary target vessel patency and primary assisted patency rates were 5.3%, 98.6% and 100%, respectively. Conclusion Implantation of f/b-EVAR in patients with failed previous EVAR is a challenging undertaking that can be performed safely with a high technical success and low reintervention rates.
Collapse
Affiliation(s)
- Jesse Manunga
- Department of Vascular and Endovascular surgery, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 E. 28th Street, Suite 300, Minneapolis, MN, 55407, USA.
| | | | - Peter Alden
- Department of Vascular and Endovascular surgery, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 E. 28th Street, Suite 300, Minneapolis, MN, 55407, USA
| | - Jason Alexander
- Department of Vascular and Endovascular surgery, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 E. 28th Street, Suite 300, Minneapolis, MN, 55407, USA
| | - Nedaa Skeik
- Department of Vascular and Endovascular surgery, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 E. 28th Street, Suite 300, Minneapolis, MN, 55407, USA
| | - Elliot Stephenson
- Department of Vascular and Endovascular surgery, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 E. 28th Street, Suite 300, Minneapolis, MN, 55407, USA
| | - Jessica Titus
- Department of Vascular and Endovascular surgery, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 E. 28th Street, Suite 300, Minneapolis, MN, 55407, USA
| | - Joseph Karam
- Department of Vascular and Endovascular surgery, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 E. 28th Street, Suite 300, Minneapolis, MN, 55407, USA
| | - Xiaoyi Teng
- Department of Vascular and Endovascular surgery, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 E. 28th Street, Suite 300, Minneapolis, MN, 55407, USA
| | - Timothy Sullivan
- Department of Vascular and Endovascular surgery, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 E. 28th Street, Suite 300, Minneapolis, MN, 55407, USA
| |
Collapse
|
26
|
Nomura Y, Nagao K, Hasegawa S, Kawashima M, Tsujimoto T, Izumi S, Matsumori M, Tanaka H, Murakami H, Honda T, Kawasaki R, Mukohara N. Outcomes of Late Open Conversion after Endovascular Abdominal Aneurysm Repair. Ann Vasc Dis 2019; 12:340-346. [PMID: 31636744 PMCID: PMC6766758 DOI: 10.3400/avd.oa.19-00009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: To review our experience with a late open conversion as a final option for an endograft infection and aneurysm expansion after endovascular aneurysm repair (EVAR), especially in endoleaks for which radiological intervention is impossible. Materials and Methods: In this retrospective study, 13 late open conversions out of 513 consecutive patients treated by EVAR were analyzed. Indications for an open conversion were aneurysm enlargement, including all endoleaks, endograft migration, and endograft infection. The patients' data on demographics, operative details, and outcomes were reviewed. Results: Indications for a late open conversion included endoleaks, infection, and migration in 61.5%, 30.8%, and 7.7% of patients, respectively. The median interval from the initial EVAR was 32.4 months. Complete endograft explantation was performed in four patients with an endograft infection. In endoleak cases, the endograft was partially preserved and a neo-neck was used. Sacotomy and branch ligation were performed in one case. One major operative complication was an aortic injury during infrarenal aortic cross-clamping in an endograft migration case. There was no operative mortality. Conclusion: A late open conversion after EVAR is valuable as a final option. The aortic cross-clamp site, especially in endograft migration cases, should be carefully considered. To avoid aneurysm-related events, graft replacement is recommended, if possible.
Collapse
Affiliation(s)
- Yoshikatsu Nomura
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
| | - Kanetsugu Nagao
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
| | - Shota Hasegawa
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
| | - Motoharu Kawashima
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
| | - Takanori Tsujimoto
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
| | - So Izumi
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
| | - Masamichi Matsumori
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
| | - Hiroshi Tanaka
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
| | - Hirohisa Murakami
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
| | - Tasuku Honda
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
| | - Ryota Kawasaki
- Department of Radiology, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
| | - Nobuhiko Mukohara
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
| |
Collapse
|
27
|
Orgera G, Tipaldi MA, Laurino F, Lucatelli P, Rebonato A, Paraskevopoulos I, Rossi M, Krokidis M. Techniques and future perspectives for the prevention and treatment of endoleaks after endovascular repair of abdominal aortic aneurysms. Insights Imaging 2019; 10:91. [PMID: 31549250 PMCID: PMC6757092 DOI: 10.1186/s13244-019-0774-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 07/22/2019] [Indexed: 12/04/2022] Open
Abstract
The presence of endoleaks remains one of the main drawbacks of endovascular repair of abdominal aortic aneurysms leading to the increase of the size of the aneurysmal sac and in most of the cases to repeated interventions. A variety of devices and percutaneous techniques have been developed so far to prevent and treat this phenomenon, including sealing of the aneurysmal sac, endovascular embolisation, and direct sac puncture. The aim of this review is to analyse the indications, the effectiveness, and the future perspectives for the prevention and treatment of endoleaks after endovascular repair of abdominal aortic aneurysms.
Collapse
Affiliation(s)
- Gianluigi Orgera
- Department of Radiology, Sant' Andrea University Hospital La Sapienza, Rome, Italy
| | | | - Florindo Laurino
- Department of Radiology, Sant' Andrea University Hospital La Sapienza, Rome, Italy
| | - Pierleone Lucatelli
- Department of Radiological Sciences, Sapienza University of Rome, Rome, Italy
| | - Alberto Rebonato
- The Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | | | - Michele Rossi
- Department of Radiology, Sant' Andrea University Hospital La Sapienza, Rome, Italy
| | - Miltiadis Krokidis
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK.
| |
Collapse
|
28
|
Juraszek A, Rylski B, Kondov S, Scheumann J, Kreibich M, Morlock J, Schröfel H, Berger T, Kari F, Siepe M, Beyersdorf F, Czerny M. Late surgical conversions after abdominal endovascular aortic repair: underlying mechanisms, clinical results and strategies for prevention. Interact Cardiovasc Thorac Surg 2019; 29:944-949. [DOI: 10.1093/icvts/ivz207] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 07/18/2019] [Accepted: 07/23/2019] [Indexed: 01/31/2023] Open
Abstract
Abstract
OBJECTIVES
Our goal was to report our results of late surgical conversion after endovascular aneurysm repair (EVAR).
METHODS
Variables analysed included baseline data, preinterventional anatomy, type of endovascular intervention, indications for conversion, operative technique, postoperative complications and follow-up survival rate.
RESULTS
Between April 2011 and May 2018, 16 patients with late complications after EVAR underwent open surgical conversion at our institution. The mean age was 73.6 [standard deviation (SD) 8.9] years. There were 3 (18.8%) female patients. In 15 patients, the indication for primary EVAR was abdominal aortic aneurysm, and in 1 patient, chronic abdominal aortic dissection. Five patients underwent secondary EVAR service interventions for endoleak treatment between the index EVAR and the final secondary surgical conversion. Thirteen patients underwent surgery in an elective setting and 3 patients underwent emergency surgery. The mean time from EVAR to open surgical conversion was 6.31 (SD 4.0) years (range 1.2–16.0 years). The most common indication for conversion was endoleak formation (n = 12, 75%), followed by 3 cases of aortic rupture (1 patient with primary type 1 endoleak) and 2 cases of stent graft infection—1 with and 1 without an aortoduodenal fistula. One patient died during emergency open surgery of cardiopulmonary instability. Three patients developed postoperative renal dysfunction with recovery of their renal function before discharge. The in-hospital mortality rate was 12.5%. The median follow-up was 16.5 months (interquartile range 21 months). Freedom from death and aortic reintervention was 100%, respectively. After careful review of the index computed tomography scans for EVAR, the majority of failures could have been anticipated due to trade-offs with regard to length, diameter, morphology, shape and angulation of the proximal and/or distal landing zone.
CONCLUSIONS
Despite being a challenging operation, late surgical conversion after EVAR yields excellent results with regard to outcome and freedom from the need for further aortic interventions. An anticipative strategy adhering to current recommendations for using or refraining from using EVAR in patients with anatomical challenges will help reduce the need for secondary surgical conversions and keep them to minimum.
Collapse
Affiliation(s)
- Andrzej Juraszek
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
- Department of Cardiac Surgery and Transplantation, The Cardinal Stefan Wyszyński Institute of Cardiology, Warsaw, Poland
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Johannes Scheumann
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Julia Morlock
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Holger Schröfel
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Tim Berger
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Fabian Kari
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| |
Collapse
|
29
|
Goudeketting SR, Fung Kon Jin PP, Ünlü Ç, de Vries JPP. Systematic review and meta-analysis of elective and urgent late open conversion after failed endovascular aneurysm repair. J Vasc Surg 2019; 70:615-628.e7. [DOI: 10.1016/j.jvs.2018.11.022] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/19/2018] [Indexed: 12/18/2022]
|
30
|
Gambardella I, Antoniou GA, Gaudino M, D'Ayala M, Girardi LN, Torella F. State of the art and meta-analysis of secondary open aortic procedure after abdominal endovascular aortic repair. J Vasc Surg 2019; 70:1341-1350.e4. [PMID: 31147115 DOI: 10.1016/j.jvs.2019.01.092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 01/19/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Secondary open aortic procedures (SOAP) treat complications of endovascular aneurysm repair, when further endovascular options are exhausted. We aimed at depicting the state of the art of SOAP with high-level evidence. METHODS A systematic review of the SOAP literature, with a meta-analysis of its outcomes (primary outcome operative mortality; secondary outcome major morbidity) and metaregression of risk factors for mortality (PROSPERO 42017075631). RESULTS Twenty-eight studies (1093 patients) were elected for analysis. SOAP was performed within the same hospitalization of or 30 days from domestic endovascular aneurysm repair (early SOAP) in 0.2% of the patients (85/40,256), and in a nonelective setting in 24.3% (95% confidence interval, 21.8-26.9). Most frequent indications were endoleak (44.4%; 95% confidence interval, 41.4-47.3) and rupture (12.7%; 95% confidence interval, 10.4-15.1). The most common procedures were infrarenal aortic replacement (85.2%; 95% confidence interval, 82.6-87.7) with high use of supravisceral clamping (suprarenal, 25% [95% confidence interval, 21.9-28.1] and supraceliac, 20.7% [95% confidence interval, 17.8-23.6]), and axillobifemoral bypass with stent explant (6.9%; 95% confidence interval, 5.1-8.7). Operative mortality (in-hospital or 30-day) was 10.9% (95% confidence interval, 8.7-13.5). The most frequent morbidities were respiratory (11.4%; 95% confidence interval, 8.1-15.9) and renal (9.5%; 95% confidence interval, 8.1-15.9). Risk factors for mortality were supravisceral clamping (Z = 3.007; Q = 9.044; P = .003) and nonelective status (Z = 3.382; Q = 11.440; P = .001). CONCLUSIONS Endoleak is the main indication for SOAP, which mostly consists of infrarenal aortic replacement. Risk factors for operative mortality are nonelective status and supravisceral clamping.
Collapse
Affiliation(s)
- Ivancarmine Gambardella
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Cornell Medical Center, New York, NY; Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Brooklyn Methodist Hospital, New York, NY.
| | - George A Antoniou
- Department of Vascular & Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, United Kingdom; Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Cornell Medical Center, New York, NY
| | - Marcus D'Ayala
- Division of Vascular Surgery, New York Methodist Hospital, Brooklyn, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Cornell Medical Center, New York, NY
| | - Francesco Torella
- Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, United Kingdom; School of Physical Sciences, University of Liverpool, Liverpool, United Kingdom
| |
Collapse
|
31
|
Lee CJ, Cuff R. Explanting the Nellix Endovascular Aortic Sealing Endoprosthesis for Proximal Aortic Neck Failure. Ann Vasc Surg 2019; 54:144.e1-144.e7. [DOI: 10.1016/j.avsg.2018.02.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 02/22/2018] [Accepted: 02/25/2018] [Indexed: 12/20/2022]
|
32
|
Law Y, Chan YC, Cheng SW. Delayed open conversion after endovascular aortic repair. Asian Cardiovasc Thorac Ann 2018; 27:80-86. [PMID: 30563352 DOI: 10.1177/0218492318820195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM We present the clinical outcomes of patients who underwent delayed (>30 days) open surgical repair after endovascular aortic aneurysm repair. METHODS All patients receiving delayed open repair of infrarenal and juxtarenal aortic aneurysms after endovascular repair from July 2001 to December 2017 were retrospectively reviewed. Patients' baseline characteristics, indications for delayed open conversion, and time between endovascular repair and open conversion are described. Early outcomes included operative approach, morbidity, and mortality. Midterm outcomes included survival. RESULTS Twenty-two (3.3%) of 667 patients with prior infrarenal endovascular aortic aneurysm repair had delayed open conversion (20 elective and 2 emergency). The time from endovascular repair to open conversion was 60 ± 36 months. The indications were 6 (27%) type Ia endoleaks, 6 (27%) type II endoleaks with enlarging sac size, 2 (9%) endotensions, 7 (32%) unknown types of endoleak, and 1 (5%) graft infection. The 7 minutes unknown endoleaks were confirmed as lumbar leaks in 4 cases and fabric leaks in 3. Operative time was 222 ± 48 min with blood loss of 2211 ± 2057 mL. Hospital stay after conversion was 12 ± 8 days. There was no 30-day mortality. Estimated survival rates were 96%, 91%, 86%, 79% and 57% at 1, 2, 3, 4, and 5 years postoperatively. CONCLUSION Delayed conversion to open surgery after endovascular aortic aneurysm repair by endograft explantation appears to be safe with good short- and mid-term outcomes. With careful preoperative assessment, open conversion remained a realistic and viable option in patients with failed endovascular treatment.
Collapse
Affiliation(s)
- Y Law
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Y C Chan
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - S W Cheng
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| |
Collapse
|
33
|
Dias AP, Farivar BS, Steenberge SP, Brier C, Kuramochi Y, Lyden SP, Eagleton MJ. Management of failed endovascular aortic aneurysm repair with explantation or fenestrated-branched endovascular aortic aneurysm repair. J Vasc Surg 2018; 68:1676-1687.e3. [DOI: 10.1016/j.jvs.2018.03.418] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 03/22/2018] [Indexed: 10/28/2022]
|
34
|
Sakalihasan N, Michel JB, Katsargyris A, Kuivaniemi H, Defraigne JO, Nchimi A, Powell JT, Yoshimura K, Hultgren R. Abdominal aortic aneurysms. Nat Rev Dis Primers 2018; 4:34. [PMID: 30337540 DOI: 10.1038/s41572-018-0030-7] [Citation(s) in RCA: 294] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
An abdominal aortic aneurysm (AAA) is a localized dilatation of the infrarenal aorta. AAA is a multifactorial disease, and genetic and environmental factors play a part; smoking, male sex and a positive family history are the most important risk factors, and AAA is most common in men >65 years of age. AAA results from changes in the aortic wall structure, including thinning of the media and adventitia due to the loss of vascular smooth muscle cells and degradation of the extracellular matrix. If the mechanical stress of the blood pressure acting on the wall exceeds the wall strength, the AAA ruptures, causing life-threatening intra-abdominal haemorrhage - the mortality for patients with ruptured AAA is 65-85%. Although AAAs of any size can rupture, the risk of rupture increases with diameter. Intact AAAs are typically asymptomatic, and in settings where screening programmes with ultrasonography are not implemented, most cases are diagnosed incidentally. Modern functional imaging techniques (PET, CT and MRI) may help to assess rupture risk. Elective repair of AAA with open surgery or endovascular aortic repair (EVAR) should be considered to prevent AAA rupture, although the morbidity and mortality associated with both techniques remain non-negligible.
Collapse
Affiliation(s)
- Natzi Sakalihasan
- Department of Cardiovascular and Thoracic Surgery, CHU Liège, University of Liège, Liège, Belgium. .,Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium.
| | - Jean-Baptiste Michel
- UMR 1148, INSERM Paris 7, Denis Diderot University, Xavier Bichat Hospital, Paris, France
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Helena Kuivaniemi
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Jean-Olivier Defraigne
- Department of Cardiovascular and Thoracic Surgery, CHU Liège, University of Liège, Liège, Belgium.,Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium
| | - Alain Nchimi
- Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium.,Department of Medical Imaging, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Koichi Yoshimura
- Graduate School of Health and Welfare, Yamaguchi Prefectural University, Yamaguchi, Japan.,Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
35
|
Kurç E, Sokullu O, Akansel S, Sargın M. Late open conversion in ruptured abdominal aortic aneurysm after endovascular repair. J Vasc Bras 2018; 17:66-70. [PMID: 29930684 PMCID: PMC5990265 DOI: 10.1590/1677-5449.008017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Despite technological advances, the long-term outcomes of endovascular aortic aneurysm repair (EVAR) are still debatable. Although most endograft failures after EVAR can be corrected with endovascular techniques, open conversion may still be required. A 70-year-old male patient presented at the emergency unit with abdominal pain. Twice, in the third and fourth years after the first repair, a stent graft had been placed over a non-adhesive portion of the stent graft due to type Ia endoleaks. In the most recent admission, a CT scan showed type III endoleak and ruptured aneurysm sac. On this occasion the patient underwent late open conversion. The failure was repaired with total preservation of the main endovascular graft body and interposition of a bifurcated dacron graft. This case demonstrates that lifelong radiographic surveillance should be considered in this subset of patients. Late open conversion following EVAR of ruptured abdominal aortic aneurysms can be performed safely.
Collapse
Affiliation(s)
- Erol Kurç
- Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Onur Sokullu
- Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Serdar Akansel
- Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Murat Sargın
- Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| |
Collapse
|
36
|
Ronchey S, Fazzini S, Scali S, Torsello G, Kubilis P, Veith F, Donas KP, Pecoraro F, Mangialardi N. Collected Transatlantic Experience From the PERICLES Registry: Use of Chimney Grafts to Treat Post-EVAR Type Ia Endoleaks Shows Good Midterm Results. J Endovasc Ther 2018; 25:492-498. [DOI: 10.1177/1526602818782941] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: The aim of this retrospective analysis was to evaluate the performance of the chimney (ch) technique in the treatment of type Ia endoleaks after standard endovascular aneurysm repair (EVAR). Methods: Between January 2008 and December 2014, 517 chEVAR procedures were performed in 13 US and European vascular centers (PERICLES registry). Thirty-nine patients (mean age 76.9±7.1 years; 33 men) were treated for persistent type Ia endoleak and had computed tomography angiography or magnetic resonance angiography follow-up at >1 month. Endurant abdominal stent-grafts were used in the 20 cases. Single chimney graft placement was performed in 18 (46%) patients and multiple in 21 (54%). Overall, 70 visceral vessels were targeted for revascularization. Results: Technical success was achieved in 35 (89.7%) cases; 3 persistent type Ia endoleaks and 1 chimney graft occlusion were detected within the first 30 days. Thirty-day mortality was 2.6%. Two other deaths (not aneurysm related) occurred during a mean follow-up of 21.9 months (0.23–71.3). Primary patency of the chimney grafts was 94.3% at 36 months. In a subgroup analysis comparing Endurant to other stent-grafts, no significant differences were observed regarding persistent endoleak [1/20 (5%) vs 2/19 (11%), p=0.6] or reintervention [1/20 (5%) vs 0/19 (0%)]. Conclusion: The present series demonstrates that chEVAR in the treatment of post-EVAR type Ia endoleaks has satisfactory results independent of the abdominal and chimney graft combinations. Midterm results show that chEVAR is an effective method for treating type Ia endoleaks.
Collapse
Affiliation(s)
- Sonia Ronchey
- Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy
| | - Stefano Fazzini
- Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy
| | - Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - Giovanni Torsello
- Department of Vascular Surgery, St Franziskus Hospital Münster, Germany
| | - Paul Kubilis
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - Frank Veith
- Cardiovascular Surgery Unit, University Hospital Zurich, Switzerland
- New York University Medical Center, New York, NY, USA
| | | | - Felice Pecoraro
- Cardiovascular Surgery Unit, University Hospital Zurich, Switzerland
- University of Palermo, Vascular Surgery Unit, AOUP “P. Giaccone”, Palermo, Italy
| | - Nicola Mangialardi
- Department of Vascular Surgery, “San Camillo-Forlanini” Hospital, Rome, Italy
| |
Collapse
|
37
|
Endovascular Aneurysm Sealing (EVAS) Alone or in Combination with Chimney Grafts (chEVAS) for Treating Complications of Previous Endovascular Aneurysm Repair (EVAR) Procedures. Cardiovasc Intervent Radiol 2018; 41:1015-1020. [DOI: 10.1007/s00270-018-1952-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 03/28/2018] [Indexed: 10/17/2022]
|
38
|
Karkos CD, Mitka M, Pliatsios I, Xanthopoulou E, Giagtzidis IT, Papadimitriou CT, Papazoglou KO. Rupture after Previous Endovascular Aneurysm Repair due to Type IA Endoleak: Complete Endograft Preservation Is Feasible with Proximal Suturing, Aortic Neck Banding, and Sac Plication. Ann Vasc Surg 2018; 49:317.e5-317.e8. [PMID: 29501905 DOI: 10.1016/j.avsg.2018.01.078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 12/31/2017] [Accepted: 01/06/2018] [Indexed: 11/19/2022]
Abstract
Rupture of an abdominal aortic aneurysm (AAA) after previous endovascular repair (EVAR) may require endograft explantation and replacement with a prosthetic surgical graft. Recent reports have suggested that total endograft removal during late surgical conversion in the nonruptured setting may not be necessary and that preserving functional parts of the endograft may improve results. Similar techniques may be used for ruptured cases diminishing the magnitude of an already difficult and complex procedure. We describe the successful treatment of a ruptured AAA after previous EVAR with complete endograft preservation by combining transmural endograft fixation with sutures, proximal aortic neck banding, and sac plication.
Collapse
Affiliation(s)
- Christos D Karkos
- 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippocrateio Hospital, Thessaloniki, Greece.
| | - Maria Mitka
- 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippocrateio Hospital, Thessaloniki, Greece
| | - Ioannis Pliatsios
- 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippocrateio Hospital, Thessaloniki, Greece
| | - Efthalia Xanthopoulou
- 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippocrateio Hospital, Thessaloniki, Greece
| | - Ioakeim T Giagtzidis
- 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippocrateio Hospital, Thessaloniki, Greece
| | - Christina T Papadimitriou
- 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippocrateio Hospital, Thessaloniki, Greece
| | - Konstantinos O Papazoglou
- 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippocrateio Hospital, Thessaloniki, Greece
| |
Collapse
|
39
|
Kakkos SK, Verhoeven EL. Open Surgical Conversion After Endovascular Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2018; 55:151-152. [DOI: 10.1016/j.ejvs.2017.11.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 11/24/2017] [Indexed: 12/12/2022]
|
40
|
Kang JH, Kim YW, Heo SH, Woo SY, Park YJ, Kim DI, Kim DK. Treatment strategy based on the natural course of the disease for patients with spontaneous isolated abdominal aortic dissection. J Vasc Surg 2017; 66:1668-1678.e3. [DOI: 10.1016/j.jvs.2017.03.435] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 03/22/2017] [Indexed: 10/19/2022]
|
41
|
Ben Abdallah I, El Batti S, Abou-Rjeili M, Fabiani JN, Julia P, Alsac JM. Open Conversion After Endovascular Abdominal Aneurysm Repair: An 8 year Single Centre Experience. Eur J Vasc Endovasc Surg 2017; 53:831-836. [DOI: 10.1016/j.ejvs.2017.03.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/02/2017] [Indexed: 12/27/2022]
|
42
|
Treatment of Type II Endoleak and Aneurysm Expansion after EVAR. Ann Vasc Surg 2017; 39:56-66. [DOI: 10.1016/j.avsg.2016.08.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/02/2016] [Accepted: 08/11/2016] [Indexed: 11/24/2022]
|
43
|
Takebayashi S, Hirota J, Mori K, Shuto T, Okamoto K, Sato A, Wada T, Anai H, Miyamoto S. Unique Technique for Open Surgical Repair after Failed Endovascular Aneurysm Repair with Proximal Anastomoses. Ann Vasc Dis 2016; 9:120-4. [PMID: 27375808 DOI: 10.3400/avd.cr.16-00012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 04/05/2016] [Indexed: 11/13/2022] Open
Abstract
Endovascular aortic aneurysm repair (EVAR) has revolutionized the management of abdominal aortic aneurysms (AAAs), with lower perioperative morbidity and mortality compared to conventional surgical repair. However, late secondary re-interventions after EVAR are still needed before aneurysm rupture in many cases. A patient with impending rupture of an AAA associated with a type I endoleak 7 years after EVAR who was successfully treated with a unique technique of fixation of the proximal aortic neck taking into account the structure of the stent graft is reported. This technique offers a safe solution to late open conversion after failed EVAR.
Collapse
Affiliation(s)
| | - Jun Hirota
- Department of Cardiovascular Surgery, Oita University, Yufu, Oita, Japan
| | - Kazuki Mori
- Department of Cardiovascular Surgery, Oita University, Yufu, Oita, Japan
| | - Takashi Shuto
- Department of Cardiovascular Surgery, Oita University, Yufu, Oita, Japan
| | - Keitaro Okamoto
- Department of Cardiovascular Surgery, Oita University, Yufu, Oita, Japan
| | - Aiko Sato
- Department of Cardiovascular Surgery, Oita University, Yufu, Oita, Japan
| | - Tomoyuki Wada
- Department of Cardiovascular Surgery, Oita University, Yufu, Oita, Japan
| | - Hirofumi Anai
- Department of Medical Engineering, Oita University, Yufu, Oita, Japan
| | - Shinji Miyamoto
- Department of Cardiovascular Surgery, Oita University, Yufu, Oita, Japan
| |
Collapse
|
44
|
Results from the Multicenter Study on Aortoenteric Fistulization After Stent Grafting of the Abdominal Aorta (MAEFISTO). J Vasc Surg 2016; 64:313-320.e1. [PMID: 27289529 DOI: 10.1016/j.jvs.2016.04.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 04/10/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This study investigated the frequency, clinical features, therapeutic options, and results of aortoenteric fistulas (AEFs) developing after endovascular abdominal aortic repair (EVAR). METHODS Eight Italian centers with an EVAR program participated in this retrospective multicenter study and collected data on AEFs that developed after a previous EVAR. RESULTS A total of 3932 patients underwent EVAR between 1997 and 2013 at the participating centers. During the same period, 32 patients presented with an AEF during EVAR follow-up, 21 with original EVAR performed for atherosclerotic aneurysmal disease (ATS group) and 11 with the original EVAR performed for a postsurgical pseudoaneurysm (PSA group). The incidence of AEF development after EVAR was 0.46% in the ATS group and 3.9% in the PSA group. Anastomotic PSA as the indication to EVAR (P < .0001) and urgent/emergency EVAR (P = .01) were significantly associated with AEF development. Median time between EVAR and the AEF diagnosis was 32 months (interquartile range, 11-75 months) for the ATS group and 14 months (interquartile range, 10.5-21.5 months) for the PSA group. Among five AEF patients treated conservatively, two (40%) died, at 7 and 15 months, and the remaining three were alive at a median follow-up of 12 months. The AEF was treated surgically in 27 patients, including aortic stent graft explantation in all cases, in situ aortic reconstruction in 14 (52%), and extra-anatomic bypass in 13 (48%). Perioperative mortality was 37% (10 of 27). No additional aortic-related death was recorded in operated-on patients at a median follow-up of 28 months. CONCLUSIONS Late AEFs rarely occur during EVAR follow-up, but the risk is significantly increased when EVAR is performed for PSA after previous aortic surgery and EVAR is performed as an emergency. Conservative and surgical treatment of post-EVAR AEF are both associated with high mortality. However, beyond the perioperative period, surgical correction of AEFs appears to be durable at midterm follow-up.
Collapse
|
45
|
Scali ST, Runge SJ, Feezor RJ, Giles KA, Fatima J, Berceli SA, Huber TS, Beck AW. Outcomes after endovascular aneurysm repair conversion and primary aortic repair for urgent and emergency indications in the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg 2016; 64:338-347. [PMID: 27288102 DOI: 10.1016/j.jvs.2016.02.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 02/02/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Open conversion after endovascular aortic aneurysm repair (EVAR-c) is performed nonelectively in up to 60% of cases. EVAR-c has been reported to have significantly greater risk of postoperative morbidity and mortality than primary aortic repair, but few data exist on outcomes for symptomatic or ruptured presentations. This study determined outcomes and identified predictors of postoperative major adverse cardiac events (MACEs) and mortality for patients undergoing nonelective EVAR-c compared with nonelective primary aortic repair (PAR) in the Vascular Quality Initiative (VQI). METHODS All VQI patients undergoing urgent/emergency EVAR-c or urgent/emergency PAR from 2002 to 2014 were reviewed. Urgent presentation was defined by repair ≤24 hours of a nonelective admission, and emergency operations had clinical or radiographic evidence, or both, of rupture. End points included in-hospital MACE (myocardial infarction, dysrhythmia, congestive heart failure) and 30-day mortality. Possible covariates identified on univariate analysis (P < .2) were entered into a multivariable model, and stepwise elimination identified the best subset of predictors. Generalized estimating equations logistic regression analysis was used to determine the relative effect of EVAR-c compared with PAR on outcomes. RESULTS During the study interval, we identified 277 EVAR-c, and 118 (43%) underwent urgent/emergency repair. nonelective PAR was performed in 1388 of 6152 total (23%). EVAR-c patients were older (75 ± 9 vs 71 ± 10 years; P < .0001), more likely to be male (84% vs 74%; P = .02), and had a higher prevalence of hypertension (88% vs 79%; P = .02) and coronary artery disease (38% vs 27%; P = .01). No differences in MACE (EVAR-c, 31% [n = 34] vs PAR, 30% [n = 398]) or any major postoperative complication (EVAR-c, 57% [n = 63] vs PAR, 55% [n = 740]; P = .8) were found; however, 30-day mortality was significantly greater in EVAR-c (37% [n = 41]) than in (PAR, 24% [n = 291]; P = .003), with an odds ratio (OR) of 2.2 (95% confidence interval [CI], 1.04-4.77; P = .04) for EVAR-c. Predictors of any MACE included age (OR, × 1.03 for each additional year; 95% CI, 1.01-1.03; P = .0002), male gender (OR, 1.3; 95% CI, 1.03-1.67; P = .03), body mass index ≤20 kg/m2 (OR, 1.8; 95% CI, 1.13-2.87; P = .01), chronic obstructive pulmonary disease (OR, 1.2; 95% CI, 0.86-1.80; P = .25), congestive heart failure (OR, 1.5; 95% CI, 0.98-2.34; P = .06), preoperative chronic β-blocker use (OR, 1.3; 95% CI, 0.97-1.63; P = .09), and emergency presentation (OR, 2.3; 95% CI, 1.8-3.01; area under the curve, 0.70; P < .0001). Significant predictors for 30-day mortality were age (OR × 1.07 for each additional year; 95% CI, 1.05-1.09; P < .0001), female gender (OR, 1.6; 95% CI, 1.01-2.46; P = .04), preoperative creatinine >1.8 mg/dL (OR, 1.6; 95% CI, 1.04-2.35; P = .03), an emergency presentation (OR, 4.8; 95% CI, 2.93-7.93; P < .0001), and renal/visceral ischemia (OR, × 1.1 for each unit increase log (time-minutes); 95% CI, 1.02-1.22; area under the curve, 0.84; P = .01). CONCLUSIONS Nonelective EVAR-c patients are older and have higher prevalence of cardiovascular risk factors than PAR patients. Similar rates of postoperative complications occur; however, urgent/emergency EVAR-c has a significantly higher risk of 30-day mortality than nonelective PAR. Several variables are identified that predict outcomes after these repairs and may help risk stratify patients to further inform clinical decision making when patients present nonelectively with EVAR failure.
Collapse
Affiliation(s)
- Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla.
| | - Sara J Runge
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Robert J Feezor
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Kristina A Giles
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Javairiah Fatima
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| |
Collapse
|
46
|
Brown A, Saggu GK, Bown MJ, Sayers RD, Sidloff DA. Type II endoleaks: challenges and solutions. Vasc Health Risk Manag 2016; 12:53-63. [PMID: 27042087 PMCID: PMC4780400 DOI: 10.2147/vhrm.s81275] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Type II endoleaks are the most common endovascular complications of endovascular abdominal aortic aneurysm repair (EVAR); however, there has been a divided opinion regarding their significance in EVAR. Some advocate a conservative approach unless there is clear evidence of sac expansion, while others maintain early intervention is best to prevent adverse late outcomes such as rupture. There is a lack of level-one evidence in this challenging group of patients, and due to a low event rate of complications, large numbers of patients would be required in well-designed trials to fully understand the natural history of type II endoleak. This review will discuss the imaging, management, and outcome of patients with isolated type II endoleaks following infra-renal EVAR.
Collapse
Affiliation(s)
- Andrew Brown
- Department of Vascular Surgery, Queens Medical Centre, University of Nottingham, Nottingham, UK
| | - Greta K Saggu
- Department of Vascular Surgery, Queens Medical Centre, University of Nottingham, Nottingham, UK
| | - Matthew J Bown
- Department of Cardiovascular Sciences, National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, University of Leicester, Leicester, UK
| | - Robert D Sayers
- Department of Cardiovascular Sciences, National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, University of Leicester, Leicester, UK
| | - David A Sidloff
- Department of Vascular Surgery, Queens Medical Centre, University of Nottingham, Nottingham, UK; Department of Cardiovascular Sciences, National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, University of Leicester, Leicester, UK
| |
Collapse
|
47
|
Lindström D, Wahlgren CM, Sonesson B, Resch T. Disintegration of the Top Stent on Zenith Abdominal Aortic Stent-Grafts. J Endovasc Ther 2016; 23:302-6. [DOI: 10.1177/1526602815626559] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To describe a heretofore unreported complication involving the Zenith Low Profile (LP) stent-graft. Case Report: Two men, aged 75 and 67 years, respectively, underwent abdominal aortic aneurysm repair with a Zenith LP device. At 4 and 3 years, respectively, computed tomography angiography revealed separation of the proximal fixation stent from the stent-graft. In the first patient, there was stent-graft migration but no evidence of an endoleak; however, the aneurysm had grown. A fenestrated cuff was placed, sealing distally in the previous LP graft. The second patient had a type I endoleak. Open surgery was performed, and the main body of the graft was explanted. Postoperative examination of the device revealed that the fixation sutures on the suprarenal stent were still attached to the stent and had eroded through the graft material. Conclusion: Physicians should be aware of the potential for top stent separation from the Zenith LP stent-graft as a cause of endoleak and migration.
Collapse
Affiliation(s)
- David Lindström
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Carl Magnus Wahlgren
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Björn Sonesson
- Vascular Center, Skåne University Hospital, Malmö, Sweden
| | - Timothy Resch
- Vascular Center, Skåne University Hospital, Malmö, Sweden
| |
Collapse
|
48
|
Steenberge SP, Lyden SP, Turney EJ, Kelso RL, Srivastava SD, Eagleton MJ, Clair DG. Outcomes after Partial Endograft Explantation. Ann Vasc Surg 2016; 31:1-7. [DOI: 10.1016/j.avsg.2015.09.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 09/14/2015] [Accepted: 09/22/2015] [Indexed: 11/29/2022]
|
49
|
Results of the Nellix system investigational device exemption pivotal trial for endovascular aneurysm sealing. J Vasc Surg 2016; 63:23-31.e1. [DOI: 10.1016/j.jvs.2015.07.096] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 07/26/2015] [Indexed: 11/21/2022]
|
50
|
Scali ST, Beck AW, Chang CK, Neal D, Feezor RJ, Stone DH, Berceli SA, Huber TS. Defining risk and identifying predictors of mortality for open conversion after endovascular aortic aneurysm repair. J Vasc Surg 2015; 63:873-81.e1. [PMID: 26613868 DOI: 10.1016/j.jvs.2015.09.058] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 09/23/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Risk of open conversion after endovascular aortic aneurysm repair (EVAR-c) is poorly defined. The purpose of this analysis was to determine outcomes of elective EVAR-c compared with elective primary open abdominal aortic aneurysm repair (PAR) in the Vascular Quality Initiative. METHODS Vascular Quality Initiative patients who underwent elective EVAR-c and PAR (2002-2014) were reviewed. Candidate predictors of major adverse cardiac event (MACE) and/or 30-day mortality were entered into a multivariable model, and stepwise elimination was used to reduce the number of covariates to a best subset of predictors. To estimate the additive risk of EVAR-c for MACE or 30-day mortality over PAR, this variable was added along with the best subset of predictors into generalized estimating equations logistic regression models. RESULTS We identified 159 EVAR-c and 3741 PAR patients. EVAR-c patients were older (73.5 ± 8.1 vs 69.5 ± 8.4 years; P < .0001), more likely to have diabetes (21% vs 15%; P = .03), and history of lower extremity bypass (9% vs 4%; P = .0006). EVAR-c was associated with a higher incidence of retroperitoneal aortic exposure (41%; n = 64 vs PAR, 26%, n = 976; P < .0001), use of a bifurcated graft (65%; n = 101 vs PAR, 52%; n = 1923; P = .001), greater blood loss (median [interquartile range], 2000 mL [1010-3500] vs PAR, 1200 mL [750-2000]; P < .0001) and longer procedure times (EVAR-c, 275 ± 122 minutes vs PAR, 232 ± 9 minutes; P < .0001). However, PAR more frequently was completed with a suprarenal and/or mesenteric cross-clamp (74%, n = 2749 vs EVAR-c, 53%, n = 83; P < .0001) and had a higher incidence of concomitant procedures (26%; n = 972 vs EVAR-c, 18%; n = 28; P = .03). Nonadjusted 30-day mortality was greater after EVAR-c: EVAR-c, 8% (n = 10) vs PAR, 3% (n = 105); P = .009. There was no difference in complication rates: EVAR-c, 33% (n = 52) vs PAR, 28% (n = 1056); P =.3. Preoperative 30-day mortality predictors included age (odds ratio [OR], 1.06/y, 95% confidence interval [CI], 1.04-1.1; P < .0001), chronic obstructive pulmonary disease (OR, 2.4; 95% CI, 1.6-3.5; P < .0001), history of leg bypass (OR, 2.3, 1.2-4.4;P =.01), suprarenal cross-clamp (OR 2.2, 1.2-4.1;P =.01), prior carotid revascularization (OR 2.2; 95% CI, 1.3-3.8; P = .0004), congestive heart failure (OR, 1.8; 95% CI, 0.9-3.5; P = .08), and female sex (OR, 1.6; 95% CI, 1.1-2.3; P = .02; area under the curve, 0.75). When controlling for covariates, EVAR-c was not significantly associated with MACE (OR, 1.2; 95% CI, 0.7-2.0; P = .4) or 30-day mortality (OR, 2.0; 0.9-4.2; P = .08). CONCLUSIONS EVAR-c patients are typically older, have more comorbidities, and experience greater blood loss and longer procedure times compared with PAR patients. However, postoperative morbidity and mortality are primarily driven by patient covariates and intraoperative factors, rather than the need for endograft explantation. Several preoperative variables were identified as predictors of 30-day mortality after elective EVAR-c and should be considered during the decision-making process for remedial treatment of failed endovascular PAR.
Collapse
Affiliation(s)
- Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla.
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Catherine K Chang
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Dan Neal
- Society for Vascular Surgery Vascular Quality Initiative Patient Safety Organization, Chicago, Ill
| | - Robert J Feezor
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| |
Collapse
|