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Xie LF, Lin XF, Wu QS, Xie YL, Zhang ZF, Qiu ZH, Chen LW. Risk prediction and prognostic analysis of post-implantation syndrome after thoracic endovascular aortic repair. Sci Rep 2024; 14:17376. [PMID: 39075074 PMCID: PMC11286741 DOI: 10.1038/s41598-024-65877-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/25/2024] [Indexed: 07/31/2024] Open
Abstract
This study aimed to establish a predictive model for the risk of post-thoracic endovascular aortic repair (TEVAR) post-implantation syndrome (PIS) in type B aortic dissection (TBAD) patients, assisting clinical physicians in early risk stratification and decision management for high-risk PIS patients. This study retrospectively analyzed the clinical data of 547 consecutive TBAD patients who underwent TEVAR treatment at our hospital. Feature variables were selected through LASSO regression and logistic regression analysis to construct a nomogram predictive model, and the model's performance was evaluated. The optimal cutoff value for the PIS risk nomogram score was calculated through receiver operating characteristic (ROC) curve analysis, further dividing patients into high-risk group (HRG) and low-risk group (LRG), and comparing the short to midterm postoperative outcomes between the two groups. In the end, a total of 158 cases (28.9%) experienced PIS. Through LASSO regression analysis and multivariable logistic regression analysis, variables including age, emergency surgery, operative time, contrast medium volume, and number of main prosthesis stents were selected to construct the nomogram predictive model. The model achieved an area under the curve (AUC) of 0.86 in the training set and 0.82 in the test set. Results from calibration curve, decision curve analysis (DCA) and clinical impact curve (CIC) demonstrated that the predictive model exhibited good performance and clinical utility. Furthermore, after comparing the postoperative outcomes of HRG and LRG patients, we found that the incidence of postoperative PIS significantly increased in HRG patients. The duration of ICU stay and mechanical assistance time was prolonged, and the incidence of postoperative type II entry flow and acute kidney injury (AKI) was higher. The risk of aortic-related adverse events (ARAEs) and major adverse events (MAEs) at the first and twelfth months of follow-up also significantly increased. However, there was no significant difference in the mortality rate during hospitalization. This study established a nomogram model for predicting the risk of PIS in patients with TBAD undergoing TEVAR. It serves as a practical tool to assist clinicians in early risk stratification and decision-making management for patients.
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Affiliation(s)
- Lin-Feng Xie
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Center for Cardiovascular Medicine, Fuzhou, Fujian, China
| | - Xin-Fan Lin
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Center for Cardiovascular Medicine, Fuzhou, Fujian, China
| | - Qing-Song Wu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Center for Cardiovascular Medicine, Fuzhou, Fujian, China
| | - Yu-Ling Xie
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Center for Cardiovascular Medicine, Fuzhou, Fujian, China
| | - Zhao-Feng Zhang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Center for Cardiovascular Medicine, Fuzhou, Fujian, China
| | - Zhi-Huang Qiu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China
- Fujian Provincial Center for Cardiovascular Medicine, Fuzhou, Fujian, China
| | - Liang-Wan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350001, Fujian, China.
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, Fujian, China.
- Fujian Provincial Center for Cardiovascular Medicine, Fuzhou, Fujian, China.
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Seretis KG, Lazaris AM, Kakisis JD. The Role of Platelets and Aneurysm Thrombus in the EVAR Post Implantation Syndrome. Ann Vasc Surg 2024; 108:375-384. [PMID: 39019256 DOI: 10.1016/j.avsg.2024.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Post implantation syndrome (PIS) is a well-defined entity with unclear etiology, complicating a number of patients with abdominal aortic aneurysms treated with endovascular aortic repair (EVAR). The aim of this study was to assess the platelets' role and the influence of aneurysmal sac thrombus volumes in the development of PIS. A retrospective analysis of prospectively collected data was performed, and 76 patients who were treated by EVAR (2011-2013) were studied. Aneurysms with endoleak were not included in the study. Based on the criteria for systemic inflammatory response syndrome (SIRS), 17 patients (22%) developed PIS (which is considered a SIRS analogue), while 59 (78%) did not. METHODS The 2 groups were compared in relation to the following parameters: baseline platelet count (PLT), decrease of platelet count (PLT drop), volume of the arterial flow before the procedure (V flow), volume of thrombus of the aneurysm (V thromb), ratio of thrombus volume to aneurysm sac volume (V ratio), and the volume of newly formed thrombus (V new). Volume flow measurements were calculated by Osirix software preoperatively and in the first month postoperatively. Parametric and nonparametric techniques (unpaired t-test, Mann-Whitney U test) were used accordingly. RESULTS Baseline platelets absolute count was greater in the PIS group (239,000 ± 17,000) versus the non-PIS group (194,000 ± 6,900, P = 0.004), and the PLT drop was larger in the PIS group (74,000 ± 15,600 versus 45,000 ± 5,300, P = 0.019). No difference was found regarding the aneurysm volumes (V flow, V thromb, V ratio, and V new) between the 2 groups. CONCLUSIONS Platelets, in terms of their absolute baseline count and their decrease after the procedure, seem to be an important factor in developing PIS after EVAR. Further, more tailored studies are needed to elucidate the role of platelets and flow or thrombus volumes in the development of PIS.
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Affiliation(s)
- Konstantinos G Seretis
- Department of Vascular Surgery, "Korgialenio-Benakio" Hospital of Hellenic Red Cross, Athens, Greece.
| | - Andreas M Lazaris
- Department of Vascular Surgery, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - John D Kakisis
- Department of Vascular Surgery, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Mannina C, Kini A, Carbone A, Neibart E, Bossone E, Prandi FR, Tadros R, Esposito G, Erbel R, Sharma SK, Lerakis S. Management of Systemic Inflammatory Response Syndrome After Cardiovascular Interventions. Diagnostic, Prognostic, and Therapeutic Implications. Am J Cardiol 2024; 221:84-93. [PMID: 38649128 DOI: 10.1016/j.amjcard.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/11/2024] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
A substantial number of patients may experience systemic inflammatory response syndrome (SIRS) and related adverse events after transcatheter aortic valve implantation and endovascular aortic aneurysm repair. Although a clear etiology has not been established, endothelial disruption and tissue-ischemic response secondary to the foreign material may represent the trigger events. A latency period (0 to 48 hours) may occur between the initial injury and onset of symptoms mirroring an initial local response followed by a systemic response. Clinical presentation can be mild or severe depending on external triggers and characteristics of the patient. Diagnosis is challenging because it simulates an infection, but lack of response to antibiotics, negative cultures are supportive of SIRS. Increased in-hospital stay, readmissions, major cardiovascular events, and reduced durability of the device used are the main complications. Treatment includes non-steroidal anti-inflammatory drugs or corticosteroids. In conclusion, further studies are warranted to fully explore pathophysiologic mechanisms underpinning SIRS and the possibility of enhancing device material immune compatibility to reduce the inflammatory reaction of the host tissue.
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Affiliation(s)
- Carlo Mannina
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Annapoorna Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, the Mount Sinai Fuster Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Andreina Carbone
- Unit of Cardiology, University Hospital "Luigi Vanvitelli", Naples, Italy; Department of Public Health, Federico II University, Naples, Italy
| | - Eric Neibart
- The Zena and Michael A. Wiener Cardiovascular Institute, the Mount Sinai Fuster Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Eduardo Bossone
- Department of Public Health, Federico II University, Naples, Italy
| | - Francesca Romana Prandi
- The Zena and Michael A. Wiener Cardiovascular Institute, the Mount Sinai Fuster Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Rami Tadros
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Giovanni Esposito
- Department of Advanced Biomedical Science, Federico II University, Naples, Italy
| | - Raimund Erbel
- Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, the Mount Sinai Fuster Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Stamatios Lerakis
- The Zena and Michael A. Wiener Cardiovascular Institute, the Mount Sinai Fuster Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York.
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Senkulak T, Oberhuber A, Yordanov M, Rukosujew A, Ibrahim A. Fever Management after TEVAR in Patients with Aortic Dissection. Zentralbl Chir 2024; 149:231-239. [PMID: 35915924 DOI: 10.1055/a-1880-1446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND Post-implantation syndrome (PIS) is characterised as a noninfectious continuous fever and a concomitant rise in inflammatory markers shortly after thoracic endovascular aortic repair (TEVAR). This current study aims to analyse the risk factors of PIS, postoperative major adverse cardiac events (MACE), and overall survival as well as the correlation between new-onset mural thrombus and the risk of developing PIS after TEVAR in patients with type B aortic dissection (TBAD). Patients were included who had a B dissection, both acute and chronic forms. In the acute form, both acutely complicated and uncomplicated patients were included in the study. A main point of our investigation is the postoperative fever management of PIS patients. METHODS A total of 90 patients with type B dissection underwent TEVAR in the University Hospital of Muenster between 2016 and 2020. The occurrence of PIS was defined as the presence of fever (> 38°C lasting longer than 24 hours in hospital) and leucocytosis (white blood cell count > 12000/µL). Patients with other possible reasons for fever and/or leucocytosis, such as a urinary tract infection (UTI), pneumonia, or sepsis, were excluded beforehand. Besides demographic and operation-related data, inflammatory markers and therapeutic measures were evaluated before and 5 days postoperatively. Computed tomography scans were examined to calculate the volume of preexistent and new-onset mural thrombus after TEVAR. RESULTS Of 90 patients, 40 patients were excluded because of recent infection or bypass surgery. Of the 50 patients included in the study, 10 patients developed post-implantation syndrome. Younger patients significantly more often developed PIS after TEVAR (52.2 ± 11.6 vs. 61.5 ± 13.6, p = 0.045). New-onset thrombus after TEVAR was significantly higher in PIS patients (61 cm³ vs. 12 cm³, p < 0.001) and PIS patients often received more medical examinations (investigation of X-ray, U status, and blood cultures). There was no significant difference in overall survival for 40 months and in the incidence of MACE. CONCLUSIONS PIS may be related to an increased rate of new-onset thrombus. A more robust conclusion is not justified according to our study. There is no difference in overall survival.
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Affiliation(s)
- Tayfun Senkulak
- Klinik für Vaskuläre und Endovaskuläre Chirurgie, Universitätsklinikum Münster, Münster, Germany
| | - Alexander Oberhuber
- Klinik für Vaskuläre und Endovaskuläre Chirurgie, Universitätsklinikum Münster, Münster, Germany
| | - Miroslav Yordanov
- Klinik für Vaskuläre und Endovaskuläre Chirurgie, Universitätsklinikum Münster, Münster, Germany
| | - Andreas Rukosujew
- Klinik für Herzchirurgie, Universitätsklinikum Münster, Münster, Germany
| | - Abdulhakim Ibrahim
- Klinik für Vaskuläre und Endovaskuläre Chirurgie, Universitätsklinikum Münster, Münster, Germany
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De Masi M, Guivier-Curien C, Cortaredona S, Omnes V, Bal L, Muselier B, Bartoli A, Gaudry M, Piquet P, Deplano V. The Value of Aortic Volume and Intraluminal Thrombus Quantification for Predicting Aortic Events after Endovascular Thoracic Aneurysm Repair. J Clin Med 2024; 13:2981. [PMID: 38792522 PMCID: PMC11122356 DOI: 10.3390/jcm13102981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/10/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
Objectives: To assess the ability of the aortic aneurysm volume (AAV), aneurysmal lumen volume (ALV), and aneurysmal thrombus volume (ATV) to predict the need for aortic reintervention when using the maximal aortic diameter as a reference. Methods: This monocentric retrospective study included 31 consecutive patients who underwent successful thoracic endovascular aortic repair (TEVAR) to treat an atheromatous thoracic aortic aneurysm. All patients underwent clinical and computed tomography angiography (CTA) for 3 years after TEVAR. The patients were categorized into group 0 if no aortic reintervention was required during the follow-up period and categorized into group 1 if they experienced a type I or III endoleak or aneurysm diameter increase requiring intervention. The maximum aneurysm sac diameter and the AAV, ALV, and ATV were calculated using CTA images obtained preoperatively (T0) and at 6-12 months (T1), 24 months (T2), and 36 months (T3) postoperatively, and their changes over time were analyzed. Correlations between diameter and changes in AAV, ALV, and ATV were assessed, and the association between diameter and volume changes and reintervetion was examined. The cutoff values for predicting the need for reintervention was determined using a receiver operating characteristic (ROC) curve. The accuracy of volume change versus diameter change for predicting the need for reintervention was analyzed. Results: There were no significant differences in terms of the mean aneurysm diameter or AAV, ALV or ATV between the groups at preoperative CTA or after one year of follow-up imaging. The mean ATV was higher in group 1 than in group 0 at 2 years (187.6 ± 86.3 mL vs. 114.7 ± 64.7 mL; p = 0.057) and after 3 years (195.0 ± 86.7 mL vs. 82.1 ± 39.9 mL; p = 0.013). The maximal diameter was greater in group 1 than in group 0 at 3 years (67.3 ± 9.5 mm vs. 55.3 ± 12.6 mm; p = 0.044). The rate of AAV change between T0 and T1 was significantly higher in group 1 (7 ± 4.5%) than in group 0 (-6 ± 6.8%; p < 0.001). The rate of ATV change between T1-T3 was significantly higher in group 1 than in group 0 (34 ± 40.9% vs. -13 ± 14.4% (p = 0.041)); similar results were observed for the rate of ATV change between T2 and T3 (27 ± 50.1% for group 1 vs. -8 ± 49.5% in group 0 (p < 0.001)). According to our multivariate analysis, the annual growth rate for AAV between T0 and T1 was the only independent factor that was significantly associated with aortic reintervention (area under the curve (AUC) = 0.84, OR = 1.57, p = 0.025; optimal cutoff +0.4%). An increase in the annual growth rate of the ATV between T0 and T3 was independently associated with the need for aortic reintervention (area under the curve (AUC) = 0.90, OR = 1.11, p = 0.0347; optimal cutoff +10.1%). Conclusions: Aortic volume analysis can predict the need for aortic reintervention more accurately and earlier than maximal aortic diameter.
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Affiliation(s)
- Mariangela De Masi
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France; (V.O.); (L.B.); (M.G.); (P.P.)
| | - Carine Guivier-Curien
- CNRS, École Centrale Marseille, IRPHE UMR 7342, Aix-Marseille University, 13384 Marseille, France; (C.G.-C.); (V.D.)
| | - Sébastien Cortaredona
- IRD, AP-HM, SSA, VITROME, Aix-Marseille University, 13009 Marseille, France;
- IHU-Méditerranée Infection, 13385 Marseille, France
| | - Virgile Omnes
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France; (V.O.); (L.B.); (M.G.); (P.P.)
| | - Laurence Bal
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France; (V.O.); (L.B.); (M.G.); (P.P.)
| | - Baptiste Muselier
- Department of Radiology, APHM, Timone Hospital, 13005 Marseille, France; (B.M.); (A.B.)
| | - Axel Bartoli
- Department of Radiology, APHM, Timone Hospital, 13005 Marseille, France; (B.M.); (A.B.)
| | - Marine Gaudry
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France; (V.O.); (L.B.); (M.G.); (P.P.)
| | - Philippe Piquet
- Timone Aortic Center, Department of Vascular Surgery, APHM, Timone Hospital, 13005 Marseille, France; (V.O.); (L.B.); (M.G.); (P.P.)
| | - Valérie Deplano
- CNRS, École Centrale Marseille, IRPHE UMR 7342, Aix-Marseille University, 13384 Marseille, France; (C.G.-C.); (V.D.)
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D'Oria M, Manoranjithan S, Scoville C, Vogel TR, Cheung S, Calvagna C, Lepidi S, Bath J. Systematic review of risk factors and outcomes of post-implantation syndrome following endovascular aortic repair. J Vasc Surg 2024; 79:1240-1250.e4. [PMID: 38122858 DOI: 10.1016/j.jvs.2023.12.029] [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: 10/16/2023] [Revised: 12/08/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Post implantation syndrome (PIS) is an early systemic inflammatory response following endovascular aortic repair (EVAR). The response is variable in patients and the clinical significance of PIS upon outcomes is unknown. This study aims to evaluate the incidence, risk factors, and prognostic implication of PIS. METHODS Systematic literature review and analysis was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and Cochrane guidelines of PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. Eligible English-language studies regarding PIS after infrarenal EVAR were included, after removing duplicates. RESULTS After screening, 31 studies were included. A total of 2847 patients were reviewed, with mean age of 70.7 years, of which 2012 (90.4%) were male, with a pooled mean follow-up of 26.1 months. PIS was reported in 25.3% of cases, with mean aneurysm diameter of 56.4 cm. Polytetrafluoroethylene (PTFE) grafts were utilized in 794 patients (27.9%) with polyester in 1839 (64.6%). White blood cell count, C-reactive protein, interleukin (IL)-6, IL-8, and IL-10 levels were all significantly elevated postoperatively. Thirty-day outcomes included type I endoleak rate of 0.8%, type II endoleak rate of 1.7%, reintervention rate of 0.35%, and mortality rate of 0.25%. Subgroup pooled analysis of patients with PIS (n = 309) vs No-PIS (n = 691) revealed that polyester (n = 642), rather than PTFE (n = 234) grafts, were associated with a higher rate of PIS (94.8% vs 3.7%; P = .0001), White blood cell count was higher in the PIS group both preoperatively (7.61 vs 6.76 × 109/L; P = .04) and postoperatively (15.0 vs 9.8 × 109/L; P = .0007) and IL-6 levels were higher in the PIS group postoperatively (98.6 vs 25.2 pg/mL; P = .02). Aneurysm diameter and amount of chronic or new thrombus within the aneurysm sac was not identified as a risk factor for PIS. Pooled outcomes of patients with PIS vs No-PIS demonstrated a significantly higher rate of 30-day mortality (0.6% vs 0%; P = .03) and major adverse cardiac events (5.8% vs 0.43%; P < .0001) without any differences seen in reintervention or 30-day type I or type II endoleaks. CONCLUSIONS This systematic review suggests that polyester grafts are strongly associated with PIS compared with PTFE. Interestingly, this report is suggestive of an association between 30-day mortality and major adverse cardiac events and PIS. Given these clinical sequelae, consideration for use of PTFE over polyester grafts to reduce the incidence of PIS may be a simple step to improve overall outcome. Further, exploration of the relationship between inflammatory mediators associated with PIS and mortality and cardiac complications may engender deeper understanding of risks, leading to eventual mitigation of harm for patients experiencing PIS.
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Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardio-Thoraco-Vascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | | | - Caryn Scoville
- Health Sciences Library, University of Missouri, Columbia, MO
| | - Todd R Vogel
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Steven Cheung
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Cristiano Calvagna
- Division of Vascular and Endovascular Surgery, Cardio-Thoraco-Vascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardio-Thoraco-Vascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Jonathan Bath
- Division of Vascular Surgery, University of Missouri, Columbia, MO.
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Wang B, Miao M, Shi Q, Xian H, Cao Y, Wang X. Impact of post-implantation syndrome on outcomes in acute type B aortic syndrome patients undergoing endovascular repair. VASA 2024; 53:53-60. [PMID: 37965717 DOI: 10.1024/0301-1526/a001102] [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] [Indexed: 11/16/2023]
Abstract
Background: The aim of this study was to explore the impact of post-implantation syndrome (PIS) on prognosis outcomes in individuals with type B acute aortic syndrome (AAS) undergoing thoracic endovascular aortic repair (TEVAR). Patients and methods: Data from type B AAS individuals who underwent TEVAR from January 2014 to April 2021 were retrospectively reviewed. Study subjects were divided into PIS and non-PIS (nPIS) groups and postoperative clinical outcomes were analyzed. Results: Our study cohort of 74 individuals with type B AAS included 40 aortic dissection (AD), 30 intramural hematoma (IMH), 4 penetrating aortic ulcer (PAU). The incidence of PIS was 14.9%. No statistically significant differences were found in baseline characteristics. The left subclavian artery (LSCA) reconstruction was performed more frequently among the PIS group (45.5% vs 9.5%, p=.008). Major adverse events (MAE) tended to be more frequent in the PIS group, but the difference was not significant (27.3% vs 22.2%, p=.707). At 2-year follow-up, results were comparable between the two groups. Kaplan-Meier analysis showed that PIS was not associated with a higher incidence of mortality, endoleak, new-onset AD, or stroke. A baseline neutrophil-to-lymphocyte ratio (NLR) >10.3 was associated with greater incidence of MAE. In individuals with IMH, better aortic remodeling evaluated by lower total aortic diameter/true lumen diameter (TAD/TLD) was achieved in the nPIS group (1.23±0.10 vs 1.43±0.07, p<.001), and a TAD/TLD ratio >1.32 was associated with significantly more MAE. Cox multivariate regression analysis also showed that a postoperative TAD/TLD ratio >1.32 was an independent risk factor for MAE (OR, 11.36; 95% CI, 1.53-84.26; p=.017). Conclusions: PIS was associated with a trend toward a higher incidence of MAE after TEVAR. In individuals with IMH, a TAD/TLD ratio >1.32 was an independent predictor of postoperative MAE.
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Affiliation(s)
- Bin Wang
- Department of Cardiovascular Surgery, Harrison International Peace Hospital, Hengshui, Hebei, China
| | - Miao Miao
- Department of Endocrinology, Harrison International Peace Hospital, Hengshui, Hebei, China
| | - Qiulin Shi
- Department of Cardiovascular Surgery, Harrison International Peace Hospital, Hengshui, Hebei, China
| | - Haiying Xian
- Department of Cardiovascular Surgery, Harrison International Peace Hospital, Hengshui, Hebei, China
| | - Yuecheng Cao
- Department of Cardiovascular Surgery, Harrison International Peace Hospital, Hengshui, Hebei, China
| | - Xiaoxiang Wang
- Department of Cardiovascular Surgery, Harrison International Peace Hospital, Hengshui, Hebei, China
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Ribeiro TF, Soares Ferreira R, Amaral C, Ferreira ME, Bastos Gonçalves F. Post-Implantation Syndrome Incidence is Higher After Complex Endovascular Aortic Procedures Than After Standard Infrarenal Repair. Eur J Vasc Endovasc Surg 2023; 66:804-812. [PMID: 37579833 DOI: 10.1016/j.ejvs.2023.08.036] [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: 02/08/2023] [Revised: 07/12/2023] [Accepted: 08/09/2023] [Indexed: 08/16/2023]
Abstract
OBJECTIVE Post-implantation syndrome (PIS), characterised by malaise, fever, and increased inflammatory markers, is a common occurrence after endovascular aneurysm repair (EVAR), causing prolonged hospitalisation and increased cost. This study aimed to determine the incidence and short-term outcomes of PIS after fenestrated or branched procedures in aorto-iliac aneurysms compared with standard EVAR. METHODS A retrospective, comparative study from a tertiary academic institution was undertaken. All patients who underwent elective EVAR with polyester stent grafts from January 2015 to June 2021 were considered. Two groups were defined: standard EVAR (sEVAR) and complex EVAR (cEVAR). The latter included visceral fenestrated and branched or iliac branch and chimney stent grafts. The primary outcome was the incidence of PIS within three days of the index procedure. Secondary outcomes were short-term complications and risk factors for PIS. A multivariable model was constructed to correct for confounders. RESULTS Overall, 253 patients were included: 165 (65.2%) sEVAR and 88 (34.8%) cEVAR. Complex EVAR patients were younger, with larger aneurysms, had longer procedures, and were more likely to have intra-operative complications. The PIS incidence was 23.7% (n = 60), significantly higher in cEVAR (34.1% vs. 18.2%; p = .005) and increased with the complexity of the procedure (EVAR: 18.2% vs. EVAR + iliac branch device: 25.0% vs. fenestrated and branched EVAR: 36.2%; p = .030). On multivariable analysis, cEVAR (OR 2.833, 95% CI 1.295 - 6.198; p = .009) was associated with a significantly increased risk of PIS. No differences in short term outcomes according to PIS status were noted. Group sub-analysis for cEVAR patients did not reveal any statistically significantly different outcomes according to PIS occurrence. CONCLUSION In this cohort, cEVAR procedures were associated with a significantly increased risk of developing PIS compared with standard infrarenal repair. Post-implantation syndrome also appears to have a benign course with no major impact on peri-operative outcomes after cEVAR. Further research to confirm these findings is required.
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Affiliation(s)
- Tiago F Ribeiro
- Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Rita Soares Ferreira
- Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Carlos Amaral
- Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Maria Emília Ferreira
- Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Frederico Bastos Gonçalves
- Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade Nova de Lisboa, Lisboa, Portugal; Hospital CUF Tejo, Lisboa, Portugal.
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9
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Li X, Wu S, Huang Y, Lun Y, Zhang J. Clinical Characteristics and Risk Factors of Noninfectious Fever after Thoracic Endovascular Aortic Repair of Acute Type B Aortic Dissection. Ann Vasc Surg 2023; 91:145-154. [PMID: 36481671 DOI: 10.1016/j.avsg.2022.11.017] [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: 07/24/2022] [Revised: 11/06/2022] [Accepted: 11/12/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) is gradually becoming a first-line treatment of complicated acute type B aortic dissection (ATBAD). Interestingly, according to years of experience in the treatment of ATBAD, we found that patients with ATBAD often had unexplained noninfectious fever after TEVAR. This study aims to explore its clinical characteristics and independent risk factors. METHODS From January 2016 to September 2021, 211 consecutive patients treated electively by TEVAR for ATBAD were included. The entry tears in all patients originated in the distal to the left subclavian artery (LSA). All patients were diagnosed with ATBAD for the first time. The definition of fever in this study was that the body temperature of patients after TEVAR exceeds 38°C. RESULTS A total of 211 patients (53.62 ± 11.34 years, 81% men) were included in the analysis. To compare patients who did and did not have post-TEVAR fever, they were respectively classified as the fever group and the nonfever group. Fever was diagnosed in 115 (55%) patients. Preoperatively, statistical differences were recorded in age (P = 0.023) and red blood cell (P = 0.037). Age <60 years [odds ratio (OR) 2.194, 95% confidence interval (CI) 1.147-4.196, P = 0.018] and duration of the operation >3 hr (OR 3.586, 95% CI 1.133-11.350, P = 0.03) were positively associated with fever. In the comparison of preoperative and postoperative experimental data, the changes in white blood cell (P = 0.046) and platelet (P = 0.007) of the 2 groups were significantly different. Hospital stay (P = 0.009) and postoperative hospital stay (P < 0.001) in the fever group were significantly prolonged. There was no difference in survival in the mid- and long-term follow-up between the 2 groups. CONCLUSIONS Noninfectious fever occurs in more than half of the patients after TEVAR (115/211, 54.5%). Patients in the fever group are younger. Age <60 years and duration of the operation >3 hr are independent risk factors for noninfectious fever in patients with ATBAD after TEVAR fever. Noninfectious fever after TEVAR may lead to prolonged hospital stay. However, it did not affect mid- and long-term prognosis.
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Affiliation(s)
- Xinyang Li
- Department of Vascular and Thyroid Surgery, The First Hospital, China Medical University, Shenyang, Liaoning, China
| | - Song Wu
- Department of Vascular and Thyroid Surgery, The First Hospital, China Medical University, Shenyang, Liaoning, China
| | - Yinde Huang
- Department of Vascular and Thyroid Surgery, The First Hospital, China Medical University, Shenyang, Liaoning, China
| | - Yu Lun
- Department of Vascular and Thyroid Surgery, The First Hospital, China Medical University, Shenyang, Liaoning, China
| | - Jian Zhang
- Department of Vascular and Thyroid Surgery, The First Hospital, China Medical University, Shenyang, Liaoning, China.
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Volevski LA, Vasiloi I, Abudureheman N, Talipov I, König A, Dielmann K, Glück AC, Andrási TB. Impact of the underlying aortic pathology on postimplantation syndrome after endovascular thoracic aortic repair. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:93-99. [PMID: 36239926 DOI: 10.23736/s0021-9509.22.12384-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) is the treatment option of choice for almost all pathologies of the descending thoracic aorta. The aim of the present study was to determine the impact of aortic pathology on the occurrence of postimplantation syndrome (PIS) after TEVAR. METHODS Seventy-four patients undergoing TEVAR for aortic dissection (TAD, 25), aortic aneurysm (TAA, 26), and aortic rupture or perforated ulcer (TAR/PAU, 23) were included in this retrospective study. The clinical outcome measures were persistent inflammation at hospital discharge and in-hospital mortality. RESULTS PIS was assessed in 22.97% of all patients, predominantly in the TAD group (P=0.03). CRP increased after TEVAR (156.6±94.5, P<0.001; 108.1±57.7, P<0.01 and 117.8±70.4, P<0.05) vs. baseline (58.1±77.5, 31.94±52.1 and 31.9±52.1 mg/L, in TAD, TAA and TAR/PAU, respectively) and this increase was more accentuated in TAD group (P<0.05). Stent-length was similar in all groups (P=0.226) but correlated with postoperative CRP only in TAD (R=0.576, P=0.013). Fresh parietal thrombus correlated with CRP (R=0.4507, P=0.0005) and is (OR=1.0883, P=0.0001), together with the pathology of aortic dissection (OR=6.2268, P=0.0288), a predictor of PIS after TEVAR. Whereas mortality (5.4%) did not correlate with PIS (P=0.38) either with aortic pathology (P=0.225), hospital stay after TEVAR was significantly prolonged by PIS (P=0.03). CONCLUSIONS Aortic dissection is associated with more inflammation after TEVAR than aortic aneurysm, rupture or perforated ulcer, with the amount of fresh parietal thrombus playing the most significant role in the occurrence of PIS. Importantly, PIS prolongs hospital stay but not mortality after TEVAR.
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Affiliation(s)
| | - Ion Vasiloi
- Department of Cardiac Surgery, Philipps University, Marburg, Germany
| | | | - Ildar Talipov
- Department of Cardiac Surgery, Philipps University, Marburg, Germany
| | - Alexander König
- Department of Radiology, Philipps University, Marburg, Germany
| | - Kai Dielmann
- Department of Anesthesiology and Intensive Care, Philipps University, Marburg, Germany
| | - Alannah C Glück
- Department of Cardiac Surgery, Philipps University, Marburg, Germany
| | - Terézia B Andrási
- Department of Cardiac Surgery, Philipps University, Marburg, Germany -
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11
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Chatzelas DA, Pitoulias AG, Telakis ZC, Kalogirou TE, Tachtsi MD, Christopoulos DC, Pitoulias GA. Incidence and risk factors of post implantation syndrome after elective endovascular aortic aneurysm repair. INT ANGIOL 2022; 41:196-204. [PMID: 35138072 DOI: 10.23736/s0392-9590.22.04759-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Post implantation syndrome (PIS) represents an acute phase systemic inflammatory response following endovascular aortic aneurysm repair (EVAR). Our objective was to investigate the risk factors associated with the manifestation and severity of PIS with various available stent-grafts. MATERIALS AND METHODS We performed a retrospective analysis of prospectively collected data covering the period 2016 - 2020. 191 patients were included. Body temperature was recorded regularly and blood sample was obtained daily. The imaging protocol included computed tomography aortoiliac angiography before surgery and one month after. The volumes of pre-existing and new-onset mural thrombus were calculated in a semiautomated fashion. Five abdominal aortic stent-graft devices were used: Endurant™ ΙΙ, Anaconda™, Treo®, E-tegra® and AFX® 2. Subgroup analysis was performed between woven polyester and ePTFE lined devices. RESULTS The incidence of PIS was 21.5%. No significant differences were observed regarding demographics, risk factors, aneurysm anatomy or operative data. The amount of preexisting and new-onset mural thrombus were not related with PIS (p=0.117 and p=0.096). PIS incidence in the polyester subgroup was 24.2%, significantly higher compared to 8.3% in the ePTFE subgroup. In-subgroup analysis revealed that the use of Anaconda™ was associated with the higher frequency (61.1%, p=0.021). Multivariate logistic regression showed that polyester was the single factor significantly associated with PIS (hazard ratio=2.6, p=0.043), as opposed to the new onset thrombus (hazard ratio=1.29, p=0.101). CONCLUSIONS PIS is not uncommon and should be taken into consideration in patients presenting with fever after EVAR. The endograft's liner material seems to play the primordial role, with woven polyester to be attributed with significantly higher incidence.
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Affiliation(s)
- Dimitrios A Chatzelas
- Division of Vascular Surgery, G. Gennimatas, Second Department of Surgery, School of Health Sciences, Faculty of Medicine, Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece - ,
| | - Apostolos G Pitoulias
- Division of Vascular Surgery, G. Gennimatas, Second Department of Surgery, School of Health Sciences, Faculty of Medicine, Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Zisis C Telakis
- Division of Vascular Surgery, G. Gennimatas, Second Department of Surgery, School of Health Sciences, Faculty of Medicine, Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Thomas E Kalogirou
- Division of Vascular Surgery, G. Gennimatas, Second Department of Surgery, School of Health Sciences, Faculty of Medicine, Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria D Tachtsi
- Division of Vascular Surgery, G. Gennimatas, Second Department of Surgery, School of Health Sciences, Faculty of Medicine, Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios C Christopoulos
- Division of Vascular Surgery, G. Gennimatas, Second Department of Surgery, School of Health Sciences, Faculty of Medicine, Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios A Pitoulias
- Division of Vascular Surgery, G. Gennimatas, Second Department of Surgery, School of Health Sciences, Faculty of Medicine, Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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12
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Nana P, Spanos K, Dakis K, Karathanos C, Kouvelos G, Giannoukas A. Factors Associated With Noninfectious Fever After Endovascular Aortic Aneurysm Repair. J Endovasc Ther 2021; 29:739-745. [PMID: 34964389 DOI: 10.1177/15266028211065966] [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] [Indexed: 12/07/2022]
Abstract
PURPOSE The post-endovascular abdominal aortic aneurysm repair (EVAR) inflammatory response, which is very often associated with fever, has been ascribed to a wide range of proinflammatory mediators and operative events. The aim of this study was to evaluate the impact of such factors in the development of fever of noninfectious origin after elective EVAR. MATERIALS AND METHODS A retrospective analysis of prospectively collected data of patients treated with standard elective EVAR between February 2017 and December 2020 was undertaken. The database included patients' demographics and comorbidities, as well as laboratory inflammatory markers (white blood cell count, neutrophils, and C-reactive protein [CRP]) and anatomical characteristics (sac diameter, inferior mesenteric artery [IMA] patency and diameter, number of patent lumbar arteries, internal iliac artery [IIA] patency or occlusion). Intraoperative details, such as type of stent graft material and IIA overstenting, were also analyzed. Patients with infectious postoperative complications or previously receiving systemic anti-inflammatory medication were excluded. Statistical analysis was performed by SPSS 22.0 for Windows software (IBM Corp, Armonk, New York). RESULTS From 332 patients treated with elective EVAR between 2017 and 2020, 268 patients (all men) were included in the analysis. The mean age was 72.1±7.5 years and the mean aneurysm diameter was 59.1±12.1 mm. Seventeen patients were excluded due to a known infection site. From the study cohort, 114 (42.5%) patients presented with fever. Multivariate regression analysis confirmed that the occlusion of IMA ≥5 mm (p<0.008) and higher CRP (p<0.001) were independent factors associated with postoperative fever. A subanalysis was performed only on patients with patent IMA before EVAR. In the multivariate regression analysis of this subgroup, IMA ≥5 mm (p=0.008), presence of dyslipidemia (p=0.037), and higher CRP (p<0.001) were related to fever. CONCLUSION Occlusion of an existing wide (≥5 mm) and patent IMA prior to EVAR may contribute to the development of post-EVAR pyrexia. The CRP is a reliable marker for post-EVAR fever. Further prospective studies are needed to corroborate these findings.
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Affiliation(s)
- Petroula Nana
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Konstantinos Dakis
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Christos Karathanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Athanasios Giannoukas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece
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13
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Soejima T, Mizunoya K, Izumi Y, Yokoyama T, Takagi R, Morimoto Y. Clinical features and significance of leukopenia occurring immediately after endovascular surgery. J Anesth 2021; 36:144-151. [PMID: 34773505 DOI: 10.1007/s00540-021-03020-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Inflammation after stent graft surgery is known as postimplantation syndrome (PIS) and it causes leukocytosis. However, we have experienced leukopenia in the very early postoperative phase of endovascular surgery at our institution. We investigated leukopenia, an under-recognized phenomenon that occurred after transcatheter aortic valve implantation (TAVI), endovascular aortic repair (EVAR), and thoracic endovascular aortic repair (TEVAR). METHODS Records of patients who underwent TAVI, EVAR, and TEVAR between March 2018 and February 2019 were retrospectively reviewed. Primary outcomes were the decline rate of white blood cell count (DR-WBC) in the immediate postoperative period and its differences among surgical procedures. The secondary endpoint was the relationship between DR-WBC and infectious complications. Furthermore, the incidence of PIS and its differences among the procedures and associations with DR-WBC were evaluated. RESULTS A total of 108 patients (TAVI 41, EVAR 37, TEVAR 30) were included. DR-WBC immediately after surgery was higher in the TAVI group when compared with other groups (TAVI, 43.1 ± 22.6%; EVAR, 27.6 ± 17.3%; TEVAR, 25.4 ± 27.4%; P < 0.01). DR-WBC was not significantly different regardless of postoperative infection (P = 0.45) or PIS (P = 0.62). The incidence rate of PIS was higher in the EVAR group compared with the TAVI group, and was not associated with DR-WBC. CONCLUSIONS Leukopenia was a common phenomenon immediately after endovascular surgery, especially TAVI. It resolved a day after surgery and was not associated with PIS or infectious complications. Therefore, it seems to be a transient abnormal hematological finding and a self-limiting condition.
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Affiliation(s)
- Takashi Soejima
- Department of Anesthesiology, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan.
| | - Kazuyuki Mizunoya
- Department of Anesthesiology, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
| | - Yuki Izumi
- Department of Anesthesiology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Takeshi Yokoyama
- Department of Anesthesiology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Ryo Takagi
- Department of Biostatistics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yuji Morimoto
- Department of Anesthesiology, Hokkaido University Hospital, N14, W5, Kita-ku, Sapporo, 060-8648, Japan
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14
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Soares Ferreira R, Oliveira-Pinto J, Ultee K, Voûte MT, Oliveira NFG, Hoeks S, Verhagen HJM, Bastos Gonçalves F. Long Term Outcomes of Post-Implantation Syndrome After Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2021; 62:561-568. [PMID: 34456118 DOI: 10.1016/j.ejvs.2021.06.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 06/12/2021] [Accepted: 06/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the association between post-implantation syndrome (PIS) and long term outcomes, with emphasis on cardiovascular prognosis. METHODS One hundred and forty-nine consecutive patients undergoing EVAR in a tertiary institution were previously included in a study investigating the risk factors and short term consequences of PIS (defined as tympanic temperature ≥ 38°C and CRP > 10 mg/L, after excluding complications with an effect on inflammatory markers). This study was based on a prospectively maintained database. Survival status was derived from inquiry of civil registry database information and causes of death from the Dutch Central Bureau of Statistics. The primary endpoint was cardiovascular events. Secondary endpoints were overall and specific cause mortality (cardiovascular, ischaemic heart disease, AAA, and cancer related mortality). Aneurysm sac dynamics and occurrence of endoleaks were also analysed. Survival estimates were obtained using Kaplan-Meier plots and a multivariable model was constructed to correct for confounders. RESULTS The PIS incidence was 39% (58/149). At the time of surgery, patients had a mean age of 73 ± 7 years and were predominantly male. There were no baseline differences between the PIS and non-PIS groups. The median follow up was 6.4 years (3.2 - 8.3), similar in both groups (p = .81). There was no difference in cardiovascular events for PIS and non-PIS patients (p = .63). However, Kaplan-Meier plots suggest a trend towards a higher rate of cardiovascular events in PIS patients during the first years: freedom from cardiovascular events at one year was 94% vs. 89% and at three years 90% vs. 82%. No differences were found in overall and specific cause mortality. There was a higher rate of type II endoleaks for non-PIS patients (28% vs. 9%, p = .005). Sac dynamics were similar in both groups. CONCLUSION The results suggest that PIS is not associated with a statistically significantly higher risk of cardiovascular events. PIS had no impact on mortality. Lastly, PIS patients had fewer type II endoleaks, but sac dynamics were analogous.
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Affiliation(s)
- Rita Soares Ferreira
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School, Universidade NOVA de Lisboa, Portugal
| | - José Oliveira-Pinto
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Angiology and Vascular Surgery, Centro Hospitalar São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Univesidade do Porto, Porto, Portugal
| | - Klaas Ultee
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Michiel T Voûte
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Nelson F G Oliveira
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Angiology and Vascular Surgery, Hospital do Divino Espírito Santo, Ponta Delgada, Azores, Portugal
| | - Sanne Hoeks
- Department of Anaesthetics, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Frederico Bastos Gonçalves
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School, Universidade NOVA de Lisboa, Portugal.
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Ibrahim A, Marchiori E, Eierhoff T, Martens S, Motekallemi A, Rukosujew A, Oberhuber A, Asciutto G. Post-implantation syndrome after frozen elephant trunk is associated with the volume of new-onset aortic thrombus. J Thorac Dis 2021; 13:4311-4321. [PMID: 34422358 PMCID: PMC8339746 DOI: 10.21037/jtd-21-398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/04/2021] [Indexed: 11/06/2022]
Abstract
Background Post-implantation syndrome (PIS) is defined as non-infectious continuous fever and a concomitant rise in inflammatory markers shortly after endovascular aortic repair. PIS occurrence after hybrid procedures, such as the frozen elephant trunk (FET) technique, has not been adequately investigated. The current study aims to define the incidence of PIS after the FET and to identify possible risk factors associated with its occurrence. Methods The clinical charts of 59 patients undergoing the FET between February 2015 and April 2020 were reviewed retrospectively. The occurrence of PIS was defined as the presence of fever (>38 °C lasting longer than one day during the hospitalisation) and leucocytosis (white blood cell count >12,000/µL). Patients with concomitant conditions possibly leading to fever and/or leucocytosis were excluded. Beside demographic and procedure-related data, serum/plasma inflammatory markers were evaluated before surgery and daily up to seven days postoperatively. Computed tomography scans (CT) were examined to calculate the volume of pre-existent and new-onset mural thrombus after the FET. Results Thirty-eight patients met the inclusion criteria. The study cohort was divided into two groups based on the occurrence of PIS (17 cases; 44.7%). Patients with PIS were significantly younger than those without PIS (53.5±8.9 vs. 62.5±9.6 years; P=0.005). Female patients were less likely to develop PIS (5.2% vs. 26.3%, P=0.018). Patients with PIS had a higher volume of new-onset thrombus in the postoperative CT (P<0.001). Patients treated for post-dissection aneurysm had, postoperatively, significantly more thrombus material developed in a false lumen (P=0.02). Among the PIS markers, CRP (C-reactive protein) levels on the third postoperative day were independently associated with the volume of new-onset thrombus (P=0.011). After multivariate analysis, the volume of new-onset thrombus (P=0.028) and age (P=0.036) remained the variable associated with a statistically significant increased incidence of PIS. Conclusions PIS can occur after the frozen elephant trunk procedure. The volume of new-onset thrombus seems to be associated with an increased incidence of PIS. These findings need to be confirmed in larger patient cohorts.
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Affiliation(s)
- Abdulhakim Ibrahim
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany
| | - Elena Marchiori
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany
| | - Thorsten Eierhoff
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany
| | - Sven Martens
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University Hospital Münster, Münster, Germany
| | - Arash Motekallemi
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University Hospital Münster, Münster, Germany
| | - Andreas Rukosujew
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University Hospital Münster, Münster, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany
| | - Giuseppe Asciutto
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany.,Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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Zoethout AC, Sheriff A, Zeebregts CJ, Hill A, Reijnen MMPJ, Holden A. Survival After Endovascular Aneurysm Sealing Compared With Endovascular Aneurysm Repair. J Endovasc Ther 2021; 28:788-795. [PMID: 34152230 DOI: 10.1177/15266028211025030] [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: 12/07/2022]
Abstract
INTRODUCTION Endovascular aneurysm sealing (EVAS) is a sac-filling device with a blunted systemic inflammatory response compared to conventional endovascular aneurysm repair (EVAR), with a suggested impact on all-cause mortality. This study compares mortality after both EVAS and EVAR. MATERIALS AND METHODS This is a retrospective observational study including data from 2 centres, with ethical approval. Elective procedures on asymptomatic infrarenal aneurysms performed between January 2011 until April 2018 were enrolled. Laboratory values (serum creatinine, haemoglobin, white blood cell count, platelet count) were measured pre- and postoperatively and at 1 and 2 years, respectively. Mortality and cause of death were recorded during follow-up. RESULTS A total of 564 patients were included (225 EVAS, 369 EVAR), after propensity score matching there were 207 patients in both groups. Baseline characteristics were similar, except for larger neck angulation and more pulmonary disease in the EVAR group. The median follow-up time was 49 (EVAS) and 44 (EVAR) months. No significant differences regarding creatinine and haemoglobin were observed. Preoperative white blood cell count was higher in the EVAR group (p=0.011), without significant differences during follow-up. Median platelet count was lower in the EVAR group preoperatively (p=0.001), but was significantly higher at 1 year follow-up (p=0.003). There were 43 deaths within the EVAS group (20.8%) and 52 within the EVAR group (25.1%) (p=0.293). Of these, 4 were aneurysm related (EVAS n=3, EVAR n=1; p=0.222) and 14 cardiovascular (EVAS n=6, EVAR n=8, p=0.845). For the EVAS cohort, survival was 95.5% at 1 year and 74.9% at 5 years. For the EVAR cohort, this was 93.3% at 1 year and 75.5% at 5 years. No significant differences were observed in causes of death. CONCLUSION This study showed comparable survival rates through 5 years between EVAS and EVAR with a tendency toward higher inflammatory response in the EVAR patients through the first 2 years.
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Affiliation(s)
- Aleksandra C Zoethout
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, The Netherlands.,Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Arshad Sheriff
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Clark J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Andrew Hill
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Michel M P J Reijnen
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, The Netherlands.,Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Andrew Holden
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
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Inoue K, Furuyama T, Kurose S, Yoshino S, Nakayama K, Yamashita S, Morisaki K, Mori M. Platelet Count Recovery after Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm. Ann Vasc Dis 2021; 14:11-18. [PMID: 33786094 PMCID: PMC7991710 DOI: 10.3400/avd.oa.20-00030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective: To find a new predictor of endoleak (EL) and aneurysm sac expansion after endovascular aneurysm repair (EVAR), we evaluated the platelet count recovery (PCR) process after EVAR. Materials and Methods: Two hundred five patients treated with elective EVAR from 2007 to 2015 were retrospectively analyzed. We compared the platelet count ratio until postoperative day (POD) 7 to the presurgical baseline between patients with and without persistent EL (≥ 6 months). Subsequently, we calculated the optimal platelet count ratio for distinguishing persistent EL using receiver-operating characteristics analysis. A platelet count ratio on POD7 ≥118% was defined as the PCR. We evaluated the PCR’s influence on the cumulative aneurysm sac expansion rate. Results: The average platelet count ratio on POD7 rose above baseline (112%), and the ratio was attenuated by persistent EL (103%). Of 205 patients, 126 (61%) were assigned to the disturbed PCR group (PCR(−) group). Cumulative aneurysm sac expansion rate was higher in the PCR(−) group than the PCR(+) group (34.4% vs. 12.8% in 5 years, p=0.01). Conclusion: Disturbed PCR after EVAR may be associated with ELs and eventual aneurysm sac expansion.
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Affiliation(s)
- Kentaro Inoue
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan.,Department of Vascular Surgery, Beppu Medical Center, Beppu, Oita, Japan
| | - Tadashi Furuyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Shun Kurose
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Shinichiro Yoshino
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Ken Nakayama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Sho Yamashita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Koichi Morisaki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Masaki Mori
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
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18
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Montelione N, Sirignano P, d'Adamo A, Stilo F, Mansour W, Capoccia L, Nenna A, Spinelli F, Speziale F. Comparison of Outcomes Following EVAR Based on Aneurysm Diameter and Volume and Their Postoperative Variations. Ann Vasc Surg 2021; 74:183-193. [PMID: 33549787 DOI: 10.1016/j.avsg.2020.12.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE to evaluate the impact of bi- and 3-dimensional preoperative aortic morphological features and their immediate postoperative variations on the outcome of abdominal aortic aneurysms (AAA) treated by endovascular exclusion with standard devices (EVAR). MATERIALS AND METHODS Double centre retrospective analysis of prospectively collected registry data of EVAR patients. For all patients, preoperative and 30-day computed tomographic angiography images (CTA) were reviewed. Preoperative maximum AAA diameter >59 mm and volume >159 cm3, and any 30-day postoperative increasing at CTA, were considered as potentially influencing the outcome. The outcome measures were: primary technical success; 30-day, 1-year, and mean follow-up reintervention, all-cause and AAA-related mortality rates, and also endoleak-related reinterventions. RESULTS Three hundred and thrity-three patients were enrolled. Mean preoperative and 30-day AAA diameter and volume were 50.4 mm ± 11.8 vs. 49.1 mm ± 12.1, and 112.9 cm3 ± 79.5 vs. 112.1 cm3 ± 80.5, respectively. Primary technical success was achieved in all cases. At 34.9 months follow-up, cumulative reintervention rate was 12.0%, mortality rates 7.2%, without AAA-related deaths. Endoleak-related reintervention rate was 7.5%. At uni- and multi-variate analysis, preoperative AAA diameter >59 mm, and AAA volume >159 cm3 were significantly associated to reintervention (P = 0.012; P = 0.002), and reintervention and death (P = 0.002; P = 0.001) during follow-up. Additionally, any increase in postoperative AAA diameter or volume was significantly associated with reintervention (P = 0.001, P = 0.001) and reintervention and death (P = 0.006, P = 0.001). Endoleak-related reintervention were also significantly associated with all of the analysed morphological parameters (P = 0.019, P = 0.005, P = 0.005, and P = 0.002, respectively). CONCLUSIONS Patients with larger baseline AAA size and volume as well as unfavourable early remodelling of the sac are associated to worse long-term EVAR outcome.
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Affiliation(s)
- Nunzio Montelione
- Vascular Surgery Division, University of Campus Bio-Medico, Rome, Italy.
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
| | - Alessandro d'Adamo
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, University of Campus Bio-Medico, Rome, Italy
| | - Wassim Mansour
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
| | - Laura Capoccia
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
| | - Antonio Nenna
- Department of Cardiovascular Surgery, University of Campus Bio-Medico, Rome, Italy
| | | | - Francesco Speziale
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
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Bradley NA, Roxburgh C, Khan F, Guthrie G. Postimplantation syndrome in endovascular aortic aneurysm repair - a systematic review. VASA 2020; 50:174-185. [PMID: 33138736 DOI: 10.1024/0301-1526/a000913] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Postimplantation syndrome (PIS) following endovascular aortic aneurysm repair (EVAR) is a poorly understood phenomenon occurring in the early post-operative course. The underlying aetiology, risk factors, clinical sequalae, and treatment options, are largely unknown. The lack of any standardised diagnostic criteria limits current research in this field. The MEDLINE database was interrogated using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) search strategy. Five search terms were used; "postimplantation syndrome" AND "aneurysm", AND "infection", AND "complications", AND "biomarkers", AND "outcomes". 19 studies were included in the review process, reporting a 17.4%-39.0% incidence of PIS. IL-6 was the most commonly elevated biomarker in PIS vs. non-PIS patients. There was a higher incidence of PIS in patients who received polyester rather than expanded-polytetrafluoroethylene (ePTFE) grafts. There was a lower rate of type 2 endoleaks observed in patients who developed PIS. Early major adverse cardiovascular events (MACE) were higher in PIS patients, however there were no studies reporting long-term MACE. Length of stay was higher in PIS patients. Current data support the role of IL-6 as being key to the development of PIS following EVAR. Further work describing the effect that PIS has on long-term clinical outcomes is needed. Lack of standardised diagnostic criteria limit the reporting of PIS between centres, the criteria proposed by this review may resolve this.
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Affiliation(s)
| | | | - Faisel Khan
- School of Medicine, University of Dundee, UK
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20
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Martinelli O, Di Girolamo A, Irace L, Baratta F, Gossetti B, Gattuso R. Post-implantation syndrome: the impact of different devices for endovascular abdominal aortic aneurysm repair and related etiopathogenetic implications. INT ANGIOL 2020; 39:398-404. [DOI: 10.23736/s0392-9590.20.04163-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Kim HO, Yim NY, Kim JK, Kang YJ, Lee BC. Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm: A Comprehensive Review. Korean J Radiol 2020; 20:1247-1265. [PMID: 31339013 PMCID: PMC6658877 DOI: 10.3348/kjr.2018.0927] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 05/02/2019] [Indexed: 12/19/2022] Open
Abstract
Abdominal aortic aneurysm (AAA) can be defined as an abnormal, progressive dilatation of the abdominal aorta, carrying a substantial risk for fatal aneurysmal rupture. Endovascular aneurysmal repair (EVAR) for AAA is a minimally invasive endovascular procedure that involves the placement of a bifurcated or tubular stent-graft over the AAA to exclude the aneurysm from arterial circulation. In contrast to open surgical repair, EVAR only requires a stab incision, shorter procedure time, and early recovery. Although EVAR seems to be an attractive solution with many advantages for AAA repair, there are detailed requirements and many important aspects should be understood before the procedure. In this comprehensive review, fundamental information regarding AAA and EVAR is presented.
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Affiliation(s)
- Hyoung Ook Kim
- Department of Radiology, Chonnam National University Hospital, Gwangju, Korea
| | - Nam Yeol Yim
- Department of Radiology, Chonnam National University Hospital, Gwangju, Korea.
| | - Jae Kyu Kim
- Department of Radiology, Chonnam National University Hospital, Gwangju, Korea
| | - Yang Jun Kang
- Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Byung Chan Lee
- Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea
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22
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Martinelli O, Di Girolamo A, Belli C, Gattuso R, Baratta F, Gossetti B, Alunno A, Irace L. Incidence of Post-Implantation Syndrome with Different Endovascular Aortic Aneurysm Repair Modalities and Devices and Related Etiopathogenetic Implications. Ann Vasc Surg 2020; 63:155-161. [DOI: 10.1016/j.avsg.2019.08.095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 11/28/2022]
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23
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Inoue K, Furuyama T, Kurose S, Yoshino S, Nakayama K, Yamashita S, Morisaki K, Kume M, Matsumoto T, Mori M. Platelets reflect the fate of type II endoleak after endovascular aneurysm repair. J Vasc Surg 2020; 72:541-548.e1. [PMID: 31980245 DOI: 10.1016/j.jvs.2019.09.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/28/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The management of type II endoleak (T2E) remains controversial because of the heterogeneous outcome. For blood-based screening to detect malignant T2E, we focused on platelets after endovascular aneurysm repair (EVAR) and compared them with the prognosis of T2Es. METHODS From 2007 to 2015, there were 249 patients treated with EVAR for abdominal aortic aneurysm who were evaluated retrospectively. The mean follow-up period was 3.5 ± 0.2 years. T2Es that had aneurysm sac enlargement or converted to type I or type III endoleak were defined as malignant; the other T2Es were considered benign. Cases without any complications, including T2E, were defined as completed. We compared the platelet count on postoperative days (PODs) 1 to 7 with preoperative baseline values among the three groups. Sequentially, we calculated the cutoff of the platelet ratio on POD 7 to the baseline value in relation to malignant T2E using receiver operating characteristic analysis, and the cutoff ratio was 113% (sensitivity, 79%; specificity, 58%). We then reclassified T2E patients into T2E-high platelet (T2E-HP; ≥113%) or T2E-low platelet (T2E-LP; <113%) groups. The influence of platelets on T2E was evaluated with reintervention rate and cumulative aneurysm sac enlargement rate using the Kaplan-Meier method. RESULTS T2Es were found in 70 patients (28%), and 179 patients were assigned to the completed group. Malignant and benign T2Es were found in 33 and 37 patients, respectively. No difference was found in the preoperative baseline values. On POD 7, the platelet count in the malignant T2E group was significantly lower than that in the completed and benign T2E groups (168 × 103/μL vs 207 × 103/μL and 201 × 103/μL; P = .0124). Then, 27 and 43 patients were assigned to the T2E-HP and T2E-LP groups, respectively. The reintervention-free survival rate in the T2E-LP group was lower than that in the completed group (at 3 years, 66.4% ± 8.0% vs 71.9% ± 4.0%; P = .0031). Among T2E patients, the cumulative aneurysm sac enlargement rates in the T2E-LP group were significantly higher than those in the T2E-HP group (at 3 years, 34.6% ± 8.2% vs 20.6% ± 8.2%; P = .0105). Univariate Cox proportional hazards analysis for the cumulative aneurysm sac enlargement rates among T2E patients showed that sex, dual antiplatelet therapy, and lower platelet ratio (<113%) were significant predictors; multivariate analysis showed that T2E-LP was the only significant predictor (hazard ratio, 2.60; P = .0355). CONCLUSIONS The platelet count of patients with malignant T2Es on POD 7 was definitively lower than that of patients with completed EVAR or with benign T2Es. The lower platelet count on POD 7 could be a risk factor for aneurysm sac enlargement among patients with T2Es.
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Affiliation(s)
- Kentaro Inoue
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Vascular Surgery, Beppu Medical Center, Beppu, Japan
| | - Tadashi Furuyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Shun Kurose
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinichiro Yoshino
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Nakayama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Sho Yamashita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koichi Morisaki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masazumi Kume
- Department of Vascular Surgery, Beppu Medical Center, Beppu, Japan
| | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare, Chiba, Japan
| | - Masaki Mori
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Early Post-EVAR Rupture in a Patient with Early Type II Endoleak: A Borderline Treatment. Ann Vasc Surg 2019; 65:285.e7-285.e9. [PMID: 31706997 DOI: 10.1016/j.avsg.2019.10.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 11/21/2022]
Abstract
PURPOSE The detection of type II endoleak one month after endovascular aneurysm repair (EVAR) is usually neglected or considered benign. Aim of this report is to present a case of post-EVAR rupture, due to type II endoleak, and discuss on pathophysiology and differential diagnosis. CASE REPORT We present a case of a 67-year-old male who was treated with EVAR for an asymptomatic abdominal aortic aneurysm and four months later, he presented with a contained rupture due to a type II endoleak. The patient was treated conservatively without any intervention with satisfying result. CONCLUSIONS We are demonstrating conservative management as a valid therapeutic option for patients presenting with a contained post-EVAR rupture.
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Cytokines as biomarkers of inflammatory response after open versus endovascular repair of abdominal aortic aneurysms: a systematic review. Acta Pharmacol Sin 2018; 39:1164-1175. [PMID: 29770795 DOI: 10.1038/aps.2017.212] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 12/31/2017] [Indexed: 01/01/2023] Open
Abstract
The repair of an abdominal aortic aneurysm (AAA) is a high-risk surgical procedure related to hormonal and metabolic stress-related response with an ensuing activation of the inflammatory cascade. In contrast to open repair (OR), endovascular aortic aneurysm repair (EVAR) seems to decrease the postoperative stress by offering less extensive incisions, dissection, and tissue manipulation. However, these beneficial effects may be offset by the release of cytokines and arachidonic acid metabolites during intra-luminal manipulation of the thrombus using catheters in endovascular repair, resulting in systemic inflammatory response (SIR), which is clinically called post-implantation syndrome. In this systematic review we compared OR with EVAR in terms of the post-interventional inflammatory response resulting from alterations in the circulating cytokine levels. We sought to summarize all the latest evidence regarding post-implantation syndrome after EVAR. We searched Medline (PubMed), ClinicalTrials.gov and the Cochrane library for clinical studies reporting on the release of cytokines as part of the inflammatory response after both open/conventional and endovascular repair of the AAA. We identified 17 studies examining the cytokine levels after OR versus EVAR. OR seemed to be associated with a greater SIR than EVAR, as evidenced by the increased cytokine levels, particularly IL-6 and IL-8, whereas IL-1β, IL-10 and TNF-α showed conflicting results or no difference between the two groups. Polyester endografts appear to be positively correlated with the incidence of post-implantation syndrome after EVAR. Future large prospective studies are warranted to delineate the underlying mechanisms of the cytokine interaction in the post-surgical inflammatory response setting.
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Regarding "Prospective evaluation of postimplantation syndrome evolution on patient outcomes after endovascular aneurysm repair for abdominal aortic aneurysm". J Vasc Surg 2018; 64:1193-4. [PMID: 27666459 DOI: 10.1016/j.jvs.2016.04.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 04/27/2016] [Indexed: 11/21/2022]
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27
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Lee JH, Choi JH, Kim EJ. Volume of mural thrombus plays a role in the elevation of inflammatory markers after endovascular aortic repair. J Cardiothorac Surg 2018; 13:27. [PMID: 29650053 PMCID: PMC5897938 DOI: 10.1186/s13019-018-0712-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although systemic inflammatory responses are common after endovascular aortic repair (EVAR), its etiology remains uncertain. It is normally well tolerated and has a benign course. This study was undertaken to investigate the possible etiology of post-EVAR inflammation by measuring volumes of chronic mural thrombus and fresh thrombus. METHODS The subjects of this study included 34 patients who underwent EVAR from February 2012 to July 2017. Inflammatory markers in all the patients were evaluated before surgery, using the highest value among the laboratory data up to 5 days after surgery, and postoperative computed tomographic angiography (CTA) was taken for all of them before their discharging. Volumes of mural thrombus and fresh thrombus were calculated by CTA. The mean interval from surgery to immediate postoperative CTA was estimated as 6.8 ± 4.0 days. RESULTS After undergoing EVAR, white blood cell (WBC) (p < 0.01), C-reactive protein (CRP) (p < 0.01) and erythrocyte sedimentation rate (ESR) (p = 0.01) were significantly elevated. Two groups were defined according to the post-implantation syndrome (PIS) by the criteria of systemic inflammatory response syndrome (SIRS);no significant differences were observed in any factors between the two groups. Classification of two groups by the criteria of increasing WBC and CRP revealed that inflammatory markers were significantly enhanced as the volume of mural thrombus increased (p = 0.03). However, no significant risk factor was found in view of aneurysmal growth after EVAR. CONCLUSION Volume of mural thrombus is an important risk factor for the elevation of inflammatory markers after EVAR.
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Affiliation(s)
- Jae Hang Lee
- Department of thoracic and cardiovascular surgery, Dongguk University Ilsan Hospital, Goyang, Gyeonggi, South Korea.
| | - Jin-Ho Choi
- Department of thoracic and cardiovascular surgery, Dongguk University Ilsan Hospital, Goyang, Gyeonggi, South Korea
| | - Eung-Joong Kim
- Department of thoracic and cardiovascular surgery, Dongguk University Ilsan Hospital, Goyang, Gyeonggi, South Korea
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Gorla R, Erbel R, Eagle KA, Bossone E. Systemic inflammatory response syndromes in the era of interventional cardiology. Vascul Pharmacol 2018; 107:S1537-1891(18)30020-X. [PMID: 29656120 DOI: 10.1016/j.vph.2018.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/25/2018] [Accepted: 04/08/2018] [Indexed: 12/27/2022]
Abstract
Systemic inflammatory response syndrome (SIRS), initially reported after cardiovascular surgery, has been described after various interventional cardiology procedures, including endovascular/thoracic aortic repair (EVAR/TEVAR), implantation of heart rhythm devices, percutaneous coronary intervention (PCI), electrophysiology procedures (EP), and transcatheter aortic valve implantation (TAVI). In these settings, a comprehensive understanding of the triggers, pathogenesis as well as a common diagnostic/therapeutic algorithm is lacking and will be discussed in this review. SIRS occurs in about 40% and 50% of patients undergoing TEVAR/EVAR and TAVI respectively; it affects 0.1% of patients undergoing implantation of heart rhythm devices. Prevalence is unknown after PCI or EP. Clinical presentation includes fever, dyspnoea/tachypnoea, tachycardia, weakness, chest pain and pericardial/pleural effusion. Several triggers can be identified, related to implanted devices, biomaterial, and procedural aspects (prolonged hypotension, aneurysm thrombus manipulation, active fixation atrial leads, coronary microembolization, balloon dilatation/stent implantantation, contrast medium, coronary/myocardial microperforation). Nonetheless, these triggers share three main pathogenic pathways leading to SIRS clinical manifestations: leucocytes activation, endothelial injury/activation, and myocardial/pericardial injury. Therapy consists of non-steroidal agents, with corticosteroids as second-line treatment in non-responders. Although a benign evolution is reported after implantation of heart rhythm devices, PCI and EP, major adverse events may occur after EVAR/TEVAR and TAVI at short- and mid-term follow up.
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Affiliation(s)
- Riccardo Gorla
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Raimund Erbel
- Institute of Medical Informatics, Biometry and Epidemiology, University Clinic Essen and University Duisburg-Essen, Essen, Germany
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29
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The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018; 67:2-77.e2. [DOI: 10.1016/j.jvs.2017.10.044] [Citation(s) in RCA: 1150] [Impact Index Per Article: 191.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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30
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Low baseline and subsequent higher aortic abdominal aneurysm FDG uptake are associated with poor sac shrinkage post endovascular repair. Eur J Nucl Med Mol Imaging 2017; 45:549-557. [PMID: 29159573 DOI: 10.1007/s00259-017-3883-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 11/08/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE The growth phases of medically treated abdominal aortic aneurysms (AAA) are frequently associated with an 18F-fluorodesoxyglucose positron emission tomography (FDG-PET) pattern involving low baseline and subsequent higher FDG uptake. However, the FDG-PET patterns associated with the endovascular aneurysm repair (EVAR) of larger AAA are presently unknown. This study aimed to investigate the relationship between serial AAA FDG uptake measurements, obtained before EVAR and 1 and 6 months post-intervention and subsequent sac shrinkage at 6 months, a well-recognized indicator of successful repair. METHODS Thirty-three AAA patients referred for EVAR (maximal diameter: 55.4 ± 6.0 mm, total volume: 205.7 ± 63.0 mL) underwent FDG-PET/computed tomography (CT) before EVAR and at 1 and 6 months thereafter, with the monitoring of AAA volume and of a maximal standardized FDG uptake [SUVmax] averaged between the axial slices encompassing the AAA. RESULTS Sac shrinkage was highly variable and could be stratified into three terciles: a first tercile in which shrinkage was absent or very limited (0-29 mL) and a third tercile with pronounced shrinkage (56-165 mL). SUVmax values were relatively low at baseline in the 1st tercile (SUVmax: 1.69 ± 0.33), but markedly increased at 6 months (2.42 ± 0.69, p = 0.02 vs. baseline). These SUV max values were by contrast much higher at baseline in the 3rd tercile (SUVmax: 2.53 ± 0.83 p = 0.009 vs. 1st tercile) and stable at 6 months (2.49 ± 0.80), while intermediate results were documented in the 2nd tercile. Lastly, the amount of sac shrinkage, expressed in absolute values or in percentages of baseline AAA volumes, was positively correlated with baseline SUVmax (p = 0.001 for both). CONCLUSION A low pre-EVAR FDG uptake and increased AAA FDG uptake at 6 months are associated with reduced sac shrinkage. This sequential FDG-PET pattern is similar to that already shown to accompany growth phases of medically treated AAA.
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Moulakakis KG, Mylonas SN, Kakisis J, Geroulakos G. Inflammatory response following stent grafting for acute aortic syndrome. Eur J Cardiothorac Surg 2015; 49:1247-8. [DOI: 10.1093/ejcts/ezv341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Sirignano P, Menna D, Capoccia L, Montelione N, Mansour W, Rizzo AR, Sbarigia E, Speziale F. Preoperative Intrasac Thrombus Load Predicts Worse Outcome after Elective Endovascular Repair of Abdominal Aortic Aneurysms. J Vasc Interv Radiol 2015; 26:1431-6. [DOI: 10.1016/j.jvir.2015.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 07/02/2015] [Accepted: 07/04/2015] [Indexed: 11/24/2022] Open
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An Update on the Inflammatory Response after Endovascular Repair for Abdominal Aortic Aneurysm. Mediators Inflamm 2015; 2015:945035. [PMID: 26166953 PMCID: PMC4488540 DOI: 10.1155/2015/945035] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 06/07/2015] [Accepted: 06/11/2015] [Indexed: 12/14/2022] Open
Abstract
Postimplantation syndrome (PIS) is the clinical and biochemical expression of an inflammatory response following endovascular repair of an aortic aneurysm (EVAR). The goal of this review is to provide an update on the inflammatory response after endovascular repair of abdominal aortic aneurysm, discussing its causes and effects on the clinical outcome of the patient. PIS concerns nearly one-third of patients after EVAR. It is generally a benign condition, although in some patients it may negatively affect outcome. The different definitions and conclusions drawn from several studies reveal that PIS needs to be redefined with standardized diagnostic criteria. The type of the endograft's material seems to play a role in the inflammatory response. Future studies should focus on a better understanding of the underlying pathophysiology, predictors, and risk factors as well as determining whether effective preventive strategies are necessary.
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Moulakakis KG, Mylonas SN, Kakisis J, Kadoglou NPE, Papadakis I, Sfyroeras GS, Antonopoulos CCN, Mantas G, Ikonomidis I, Liapis CD. Arterial Stiffness Alterations and Inflammatory Response Following Endovascular Aortic Repair: Based on a Presentation at the 2013 VEITH Symposium, November 19-23, 2013 (New York, NY, USA). AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2015; 3:75-80. [PMID: 26798761 DOI: 10.12945/j.aorta.2015.14-071] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 03/27/2015] [Indexed: 11/18/2022]
Abstract
Endovascular abdominal aortic aneurysm repair (EVAR) and thoracic aortic aneurysm repair (TEVAR) have been widely incorporated into clinical practice. However, changes in arterial stiffness and post-implantation syndrome after aortic endografting remain important issues under investigation. The aneurysm sac wall motion after successful EVAR and TEVAR reflects complex interactions between all the components of the excluded aneurysm, including true compliance of the aneurysm wall itself, intra-aneurysm sac pressure, remodeling of the thrombus, and mechanical characteristics of the endograft. Experimental and clinical studies have shown that aortic endografting results in increased arterial stiffness in animal models. It can be assumed that the alterations of aortic mechanical properties can have a direct impact on heart output. The long-term impact of these mechanical changes on cardiovascular outcomes and the potential effects of different endografts on hemodynamics are important issues under investigation. Post-implantation syndrome (PIS) is a systemic inflammatory response frequently observed after endovascular treatment of aortic pathologies. The main features of PIS include fever, leukocytosis, elevated C-reactive protein levels, and coagulation disturbances. Endograft design appears to influence this inflammatory response following aortic endografting; woven polyester endografts have been shown to be associated with greater inflammatory response compared to PTFE stent grafts. The purpose of this paper is to review the literature to elucidate arterial stiffness alterations and inflammatory response after EVAR and TEVAR and the impact of endograft design on aortic stiffness and the post-inflammatory response.
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Affiliation(s)
| | - Spyridon N Mylonas
- Department of Vascular Surgery, Medical School, University of Athens, Greece
| | - John Kakisis
- Department of Vascular Surgery, Medical School, University of Athens, Greece
| | | | - Ioannis Papadakis
- Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - George S Sfyroeras
- Department of Vascular Surgery, Medical School, University of Athens, Greece
| | | | - George Mantas
- Department of Vascular Surgery, Medical School, University of Athens, Greece
| | | | - Christos D Liapis
- Department of Vascular Surgery, Medical School, University of Athens, Greece
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Arnaoutoglou E, Kouvelos G, Papa N, Kallinteri A, Milionis H, Koulouras V, Matsagkas M. Prospective evaluation of post-implantation inflammatory response after EVAR for AAA: influence on patients' 30 day outcome. Eur J Vasc Endovasc Surg 2015; 49:175-83. [PMID: 25579873 DOI: 10.1016/j.ejvs.2014.12.006] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 12/03/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim was to prospectively evaluate post-implantation syndrome (PIS) after elective endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) and to investigate its association with clinical and laboratory parameters and the clinical outcome of the patients. METHODS From January 2010 till June 2013, 214 consecutive patients treated electively by EVAR for AAA were prospectively included. PIS was defined according to systemic inflammatory response syndrome criteria. Adverse events included any major adverse cardiovascular events (MACE), acute renal failure, re-admission and death from any cause. RESULTS PIS was diagnosed in 77 (34%) patients. Pre-operative white blood cell (WBC) count values (p < .001), endograft material (polyester) (p < .001), and heart failure (p = .03) were independent predictors of PIS. Mean post-operative temperature (p < .001), length of hospital (p < .001) and intensive care unit (p = .008) stay, as well as maximum post-operative WBC count (p < .001) and hs-CRP values (p < .001) were significantly higher in the PIS group. Post-operative hs-CRP (p = .001) and duration of fever (p = .02) independently predicted the occurrence of MACE. Post-operative hs-CRP (p = .004), maximum temperature (p = .03), and the presence of PIS (p = .01) were independent predictors of an adverse event during the first 30 days. A threshold of post-operative hs-CRP value of 125 mg/L was highly associated with the occurrence of MACE, with a sensitivity of 82% and specificity of 75%. CONCLUSIONS A systematic inflammatory response is observed in a significant number of patients after EVAR. The type of endograft material seems to play a significant role in this inflammatory process. The intensity of inflammation, as assessed mainly by the post-operative hs-CRP values, correlates with the presence of a cardiovascular or any other adverse event during the first 30 days after the procedure.
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Affiliation(s)
- E Arnaoutoglou
- Department of Anesthesiology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - G Kouvelos
- Department of Surgery - Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - N Papa
- Department of Surgery - Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - A Kallinteri
- Laboratory of Immunology and Microbiology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - H Milionis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - V Koulouras
- Department of Intensive Care Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - M Matsagkas
- Department of Surgery - Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece.
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