Debate: Whether young, good-risk patients should be treated with endovascular abdominal aortic aneurysm repair

Intra-Sac Injection of Thrombin During Endovascular Aneurysm Repair to Remedy Type II Endoleak and Promote Sac Shrinkage

PURPOSE

To evaluate the safety and effectiveness of intra-sac thrombin injection to remedy type II endoleaks (T2ELs) during endovascular aneurysm repair (EVAR).

MATERIALS AND METHODS

224 cases abdominal aortic aneurysm (AAA) were treated with EVAR. For the 52 cases of intra-operative type II endoleaks and 8 cases of ruptured AAAs, after the grafts were deployed, thrombin was injected into the aneurysm sac through a preset catheter. The occurrence of endoleaks post-EVAR were followed up with by Computed Tomography (CT) angiogram. The diameter and the volume of the aneurysm sac were also measured. Endpoints included incidence of T2ELs, AAA sac shrinkage and re-intervention rate and all-cause mortality.

RESULTS

The overall technical success rate was 100%. Fifty-two patients were followed up with for 9-56 (median 24) months. No serious complications were observed during follow-up. The incidence of endoleak was 5.8% (3/52) during follow-up. The maximum diameter of the aneurysm decreased from 61.1 ± 14.2 mm to 53.7 ± 10.6 mm, 47.9 ± 8.3 mm and 43.7 ± 7.2 mm (87.9%, 78.4% and 71.5% of pre-EVAR) at the 6-month, 1-year and 2-year follow-up, respectively (P < .05). The volume of the aneurysm sac shrank from 236.2 ± 136.2 cm3 to 202.6 ± 114.1 cm3, 155.6 ± 68.4 cm3 and 129.7 ± 52.4 cm3 (85.8%, 65.9%, and 54.9% of pre-EVAR) at the 6-month, 1-year and 2-year follow-up, respectively (P < .05). The rate of various endoleaks was 5.8% (3/52) and the re-intervention rate was 1.9% (1/52) in this research.

CONCLUSIONS

Clinical outcomes show that intra-sac injection of thrombin during EVAR is safe and may be effective in remedying small amount and low-velocity endoleaks and promoting shrinkage of the aneurysm sac.

Impact of Previous Open Abdominal Surgery on Open Abdominal Aortic Repair: A Study from the NSQIP Database

BACKGROUND

While endovascular aneurysm repair has become a first-line strategy in many centers, open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) is still the best option for certain patients. A significant number of patients who are offered OSR for AAA have been previously submitted to other open abdominal surgeries (PAS). It is unclear, however, how this may impact their outcomes. The purpose of this study was to determine if there is an association between PAS and outcomes of OSR of AAA.

METHODS

This is a retrospective cohort study based on clinical data from the American College of Surgeons National Surgical Quality Improvement Program database, including all patients undergoing elective OSR for AAA between 2011 and 2017. Excluded were patients with missing data on prior abdominal surgery, supramesenteric clamping, or urgent repairs. Patients with prior abdominal surgery (PAS) and patients without prior abdominal surgeries (nonPAS) were compared. The primary outcome was 30-day postoperative mortality. Secondary outcomes were operating time, ischemic colitis, postoperative complications, and lengths of hospital stay.

RESULTS

Of the 2034 patients included, 27% had previous open abdominal surgery and 73% did not. Overall, the median age was 71(interquartile range 65-76), 72% of patients were male, 44% were smokers, and the average body mass index was 27 kg/m2. Univariate analysis showed no difference in postoperative 30-day mortality (4.0% PAS vs. 4.1% nonPAS, P = 0.91) or overall postoperative complication rates (33% PAS vs. 29% nonPAS, P = 0.07). Previous open abdominal surgery was significantly associated with longer operating times (P = 0.032) and an almost doubled rate of ischemic colitis (4.7% PAS vs. 2.6% nonPAS, P = 0.02). Postoperative intensive care unit and hospitalization were also significantly longer in patients with prior abdominal surgery (P = 0.005 and P = 0.014, respectively). Finally, there were significantly less patients discharged home, as opposed to institutionalized care (75.7% PAS down from 82.4% nonPAS, P = 0.001). Despite these initial univariate analysis results, on multivariate analysis, PAS actually did not prove to be a statistically significant independent risk factor for 30-day mortality, ischemic colitis, or longer operating times.

CONCLUSIONS

This study suggests that patients who have undergone PAS may have some disadvantages in OSR of AAA. However, these negative trends do not go so far as to statistically significantly identify PAS as an independent risk factor for 30-day mortality, ischemic colitis, or longer operating times. As such, we suggest that a history of previous open abdominal surgery, in and of its own, should not exclude patients from consideration for open aortic abdominal aneurysm repair.

Long-term age-stratified survival following endovascular and open abdominal aortic aneurysm repair

OBJECTIVE

The long-term survival differences between endovascular and open repair for abdominal aortic aneurysms and specifically the impact of age on these differences remain a topic of debate. Therefore, we compared the long-term mortality between endovascular and open abdominal aneurysm repair for patients of different ages.

METHODS

This was a retrospective cohort study of prospectively collected data from patients undergoing elective endovascular or open repair for infrarenal abdominal aortic aneurysms within the Vascular Quality Initiative multi-national clinical registry (2003-2021). The primary outcome was long-term all-cause mortality comparing endovascular and open repair for patients aged <65 years, between 65-79 years, and those aged ≥80. In addition, we investigated the interaction between repair modality and ten-year hazard of mortality for sex, aneurysm diameter, and several pre-operative comorbid conditions within each age category. To account for non-random assignment of treatment, we used propensity scores and inverse probability weighted Cox proportional hazard analysis.

RESULTS

We identified 48,074 patients undergoing elective infrarenal abdominal aneurysm repair (89% endovascular) within the study period, including 7,940 patients aged <65, 29,555 aged between 65-79, and 10,579 aged ≥80 years. EVAR was associated with a higher propensity score-adjusted long-term hazard of mortality compared to open repair in the cohort aged <65 years (hazard ratio [HR]: 1.39; 95% confidence interval [CI]: 1.04-1.86; P=.026). The mortality was similar in the age cohort between 65-79 (HR: 0.94; 95%CI: 0.79-1.10; P=.43), while EVAR was associated with a lower hazard of mortality in the cohort aged ≥80 years (HR: 0.63; 95%CI: 0.46-0.86; P=.004). In patients aged <65, the hazard of mortality was higher with endovascular compared with open repair in those with female sex (HR: 4.40; 95%CI: 1.75-11.0), an aneurysm diameter >65mm (HR: 2.19; 95%CI: 1.11-4.34), and absence of coronary artery disease (HR: 1.26; 95%CI: 0.83-1.91), congestive heart failure (HR: 1.41; 95%CI: 1.03-1.92), and renal dysfunction (HR: 1.46; 95%CI: 1.04-2.05). In the patient cohort aged ≥80, a lower hazard of mortality for endovascular vs. open repair was observed for male patients, or those with small aneurysms or certain comorbidities.

CONCLUSIONS

In a selected group of young patients with a substantial life expectancy, the long-term mortality is higher with endovascular compared to open repair for infrarenal abdominal aortic aneurysms. Long-term mortality with endovascular repair is similar in the middle cohort and lower in the elderly cohort compared to open repair.

Early and Long-Term Outcomes of Endovascular Aortic Repair in Young and Low Surgical Risk Patients in the Global Registry for Endovascular Aortic Treatment

PURPOSE

To investigate early- and long-term outcomes of endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA) in young and low surgical risk patients.

METHODS

The global registry for endovascular aortic treatment (GREAT) was queried for all patients with AAA undergoing standard EVAR; patients were excluded if had previous AAA repair or underwent concomitant procedures. Young patients were defined if age <60; surgical risk was assessed through the validated Medicare perioperative risk score (MPRS) based on age, sex, renal function, heart failure, and peripheral vascular disease. Patients were classified as low (MPRS<3), average (MPRS 3-11), or high (MPRS>11) risk. Young versus older patients and low-risk versus average/high-risk patients were compared. The primary endpoints were early (30 days) major adverse events (MAEs), 5-year freedom from overall mortality, aortic-related mortality, and freedom from device-related reinterventions. Time-to-event endpoints were calculated by Kaplan-Meier curves.

RESULTS

Of 3217 included patients, 182 (6%) were <60 years old, 956 (30%) had a low surgical risk, 1561 (49%) an average risk, 700 (22%) a high risk. Young patients had a less angulated proximal neck (27.2±18.4° vs 30.9±21.5°; p=0.05); in low-risk compared to average/high-risk patients, a longer neck length (3±1.8 vs 2.8±1.4 cm; p=0.01) and lower neck angulation (29.7±21.8° vs 33.2±22.2°; p=0.01) were present. Young age alone had no significant impact on early mortality (0% vs 0.6%; p=0.62.) and MAEs (3.9% vs 6.1%; p=0.20), while these were significantly lower in low-risk compared to average/high-risk patients (early mortality: 0.1% vs 0.7%, p=0.04; MAEs: 4.1% vs 6.7%, p=0.005). At 5 years, overall survival was significantly higher in young (88% vs 76%; p<0.001) and lower-risk (77% vs 54%; p<0.001) patients; low-risk patients also had significantly decreased aortic-related mortality (0% vs 2%; p=0.04) and reintervention rates (6% vs 11%; p=0.007). There were no statistically significant differences in mortality (0% vs 2%; p=0.42) and reintervention rate (10% vs 10%; p=1.00) between young and older patients.

CONCLUSION

In this real-world registry, EVAR was more often offered in cases with suitable anatomy in young and low-risk patients. Low operative risk, rather than young age alone, predicted excellent early outcomes and low 5-year mortality, aortic-related mortality, and reintervention rates.

The Role of Duplex Ultrasound in Detecting Graft Thrombosis and Endoleak after Endovascular Aortic Repair for Abdominal Aneurysm

BACKGROUND

To assess the role of duplex ultrasound (DUS) in detecting endoleaks (ELs) and graft thrombosis (GT) in a cohort of patients submitted to endovascular aortic repair (EVAR) for elective infrarenal abdominal aortic aneurysm (AAA) in 2 centers.

METHODS

Data, of all consecutive patients treated in 2 operative units of vascular surgery, from January 01, 2000 to December 31, 2016, were retrospectively collected and evaluated. Follow-up data were analyzed to evaluate survival and device-related complications, both at 30-day and in the midterm. The results of computed tomography angiography (CTA) and DUS which were performed yearly, with a time interval between the 2 examinations lower than 30 days, were paired in terms of maximum transverse diameters of the aneurysmal sac, identification of EL, and of GT. Sensibility (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), and accuracy (ACC) of the DUS were calculated with respect to data of each paired CTA and to data of the real clinical diagnosis of either EL or GT. A Student's t-test was performed to compare the aneurysmal sac diameters measured with DUS to those of CTA. "Kappa" coefficient of agreement was also calculated. A P value < 0.05 was the level reference for statistical significance.

RESULTS

A total of 920 patients (104 female, 11.3%) underwent EVAR for elective infrarenal AAA. Technical success was achieved in 910 cases (98.9%). At 30 days, there were 5 deaths (0.5%), no GT, and 3 small type II ELs which did not require any adjunctive procedure. Mean follow-up was 64.8 months (range 1-120.3 months). Survival and freedom from complications were estimated to be 78.4% ± 1.9% and 48.3% ± 1.7%, respectively, at 10 years. Seventy-six more ELs and 8 GTs were recorded. Considering the CTA as the gold standard, SE, SP, and ACC of DUS in the detection of the EL were 93.2% ± 5.8%, 98.8% ± 1.1%, and 97.8%, respectively, with a PPV of 94.5% ± 5.2% and a NPV of 98.3% ± 1.4%. Considering, however, the real diagnosis of the EL, SE, SP, and ACC of DUS were slightly lower (89.4% ± 6.9%, 98.5% ± 1.3%, and 96.9%, respectively), as well as PPV and NPV (93.1% ± 5.8% and 97.7% ± 1.6%, respectively). K coefficient of agreement between the measurements of the sac maximum transverse diameter recorded at DUS and CTA was 0.91, with a little underestimation of the aneurysm diameter at DUS if compared with CTA (mean diameter difference of 2.5 mm, 95% confidence interval: 2.25-2.75 mm).

CONCLUSIONS

DUS has proven to be a reliable examination in identifying all GT and most ELs after EVAR, compared with CTA. A good correlation was also observed between the measurements of the sac maximum transverse diameter recorded at DUS and CTA, with a little underestimation of the aneurysm diameter at DUS compared with CTA.

Postoperative imaging of the aorta

Considerable progress has been made in the management of diseases of the thoracic and abdominal aorta over the past decades, ranging from advances in open repair to the advent of minimally invasive endovascular techniques. Along with this comes an equivalent rise in imaging necessity for these patients, both in preoperative planning and postoperative surveillance. With the growing complexity and diversity of vascular procedures and techniques, it is essential to have a solid understanding of the imaging features and postoperative complications of these procedures to avoid imaging pitfalls. This review is an attempt to define the normal postoperative appearance and important complications of various open and endovascular surgical techniques of the thoracic and abdominal aorta.

Radiation Exposure in Endovascular Infra-Renal Aortic Aneurysm Repair and Factors that Influence It

Objective

The endovascular repair of aortic abdominal aneurysms exposes the patients and surgical team to ionizing radiation with risk of direct tissue damage and induction of gene mutation. This study aims to describe our standard of radiation exposure in endovascular aortic aneurysm repair and the factors that influence it.

Methods

Retrospective analysis of a prospective database of patients with abdominal infra-renal aortic aneurysms submitted to endovascular repair. This study evaluated the radiation doses (dose area product (DAP)), fluoroscopy durations and their relationships to the patients, aneurysms, and stent-graft characteristics.

Results

This study included 127 patients with a mean age of 73 years. The mean DAP was 4.8 mGy.m², and the fluoroscopy time was 21.8 minutes. Aortic bilateral iliac aneurysms, higher body mass index, aneurysms with diameters larger than 60 mm, necks with diameters larger than 28 mm, common iliac arteries with diameters larger than 20 mm, and neck angulations superior to 50 degrees were associated with an increased radiation dose. The number of anatomic risk factors present was associated with increased radiation exposure and fluoroscopy time, regardless of the anatomical risk factors.

Conclusion

The radiation exposure during endovascular aortic aneurysm repair is significant (mean DAP 4.8 mGy.m²) with potential hazards to the surgical team and the patients. The anatomical characteristics of the aneurysm, patient characteristics, and the procedure's technical difficulty were all related to increased radiation exposure during endovascular aortic aneurysm repair procedures. Approximately 40% of radiation exposure can be explained by body mass index, neck angulation, aneurysm diameter, neck diameter, and aneurysm type.

Improving Patient Compliance With Post-EVAR Surveillance May Prevent Late Rupture

Endovascular aneurysm repair (EVAR) has gained increasing popularity in the treatment of infrarenal abdominal aortic aneurysm. Despite its favorable early outcomes, the long-term efficacy of EVAR remains a concern. Late rupture is the ultimate treatment failure and continues to complicate EVAR. Univariate and multivariate analyses have identified factors predictive of late rupture. The importance of EVAR surveillance to prevent late complications is equally widely acknowledged. This article aims to present our current understanding of the precipitating factors of late rupture after EVAR and explores whether the key to its prevention lies within improving patient factors, particularly compliance to follow-up appointments or whether physicians hold the solution.

Open and endovascular elective treatment of abdominal aortic aneurysms: a real-world experience

PURPOSE

To present a real-world experience of the elective treatment of abdominal aortic aneurysms (AAAs) using both open repair (OR) and endovascular repair (EVAR).

METHODS

Data from patients treated consecutively between January 1, 2000 and December 31, 2014 were collected retrospectively and reviewed. The primary outcomes were 30-day mortality and complication rates, freedom from reintervention, and survival in the long-term.

RESULTS

We analyzed data on 1112 patients (660 EVAR, 452 OR). The 30-day mortality and complications rates were higher after OR than after EVAR (2.9 vs. 1.1%, P = .03 and 24.7 vs. 1.1%, P < .0001, respectively). At 10 years, survival was 66.1 ± 3.2% after OR and 78.1 ± 2.2% after EVAR (P = .0006) and freedom from reintervention was 93.5 ± 1.8% after OR and 88.4 ± 1.8% after EVAR (P = .005). The preoperative aneurysm diameter was significantly associated with the development of type Ia endoleaks after EVAR (P < .0001) and of a proximal pseudoaneurysm after OR (P < .0001).

CONCLUSION

In the long-term, EVAR was associated with higher reintervention rates, but better survival than OR. The preoperative AAA diameter was the most important predictor of the development of endoleaks after EVAR and proximal pseudoaneurysm after OR.

Endovascular treatment of abdominal aortic aneurysm in a 26-year-old man. A case report and 10-year follow-up

We present endovascular treatment of abdominal aortic aneurysm in a 26-year-old man with a 10-year follow-up. A young patient presenting with an abdominal aortic aneurysm is extremely rare, and data describing this population are limited. Open aneurysm repair (OAR) is the treatment of choice in these patients. However, since its introduction, endovascular aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysms. The long-term durability and late complications after EVAR may have more significance when considering the optimal treatment for young patients with a longer life expectancy. Our good long-term outcome will help to support the use of EVAR as a reasonable alternative to OAR in young patients with suitable anatomic findings.