Performance of the Endurant stent graft in challenging anatomy

The Effect of One Year Aneurysm Sac Dynamics on Five Year Mortality and Continued Aneurysm Sac Evolution

OBJECTIVE

One year aneurysm sac dynamics after endovascular abdominal aortic aneurysm repair (EVAR) were independently associated with a greater all cause mortality risk in prior registry studies but were limited in completeness and granularity. This retrospective analysis aimed to study the impact of sac dynamics on survival within the Endurant Stent Graft Global Registry (ENGAGE) with five year follow up.

METHODS

A total of 1 263 subjects were enrolled in the ENGAGE Registry between March 2009 and April 2011. One year aneurysm sac changes were calculated between the one month post-operative imaging scans and the scan closest to the time of one year follow up. Sac regression was defined as a sac decrease of ≥ 5 mm and sac expansion as aneurysm sac growth ≥ 5 mm. The primary outcome was the five year all cause mortality rate. Kaplan-Meier estimates for freedom from all cause death were calculated. Multivariable Cox regression was used to determine the association between sac dynamics and all cause death.

RESULTS

At one year, 441 of the 949 study participants with appropriate imaging (46%) had abdominal aortic aneurysm sac regression, 462 (49%) remained stable, and 46 (4.8%) had sac expansion. For patients with sac regression, the five year all cause mortality rate was 20%, compared with 28% for stable sac (p = .007) and 37% for the sac expansion (p = .010) cohorts. After adjustment, the sac expansion and stable sac cohorts were associated with a greater all cause mortality rate (expansion: hazard ratio [HR] 1.8; 95% CI 1.1 - 3.2; p = .032; stable: HR 1.4; 95% CI 1.1 - 1.9; p = .019).

CONCLUSION

In the ENGAGE Global Registry, the one year rate of sac regression was 46%, and one year sac regression was observed to be associated with greater five year survival, corroborating prior findings using data from vascular registries. Sac regression could become the new standard for success after EVAR.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE/BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Systematic Review of the Recruitment and Outcome Reporting by Sex and Race/Ethnicity in Stent Device Development Trials for Endovascular Abdominal Aortic Aneurysm Repair

BACKGROUND

Women and racial/ethnic minority groups have been shown to experience poor outcomes after endovascular aortic aneurysm repair (EVAR). One potential reason is the rare inclusion of these populations in initial phases of device development. The objective of this systematic review is to understand enrollment and outcome reporting by sex and race/ethnicity in industry-funded EVAR device development trials.

METHODS

MEDLINE, PubMed, and Embase were searched from inception to January 2022 without language restrictions using the following terminology: "stent", "graft", "endograft", "device", and "abdominal aortic aneurysm" (AAA).

CLINICALTRIALS

gov was also searched from inception to January 2022 for "AAA." Two independent reviewers screened and extracted data. All phase I-III and postmarket evaluation trials that included patients ≥18 years of age, who underwent EVAR were assessed. Participation-to-prevalence ratios (PPRs) were calculated to estimate representation of participants by sex and race/ethnicity in trials compared with their share of disease burden.

RESULTS

Among the 4,780 retrieved articles, 55 industry-funded trials met inclusion criteria for this review. A total of 51 trials (93%) reported enrollment by sex/gender, and only 7 trials (13%) reported enrollment by race/ethnicity of the participants. A median of 19 (interquartile range [IQR]: 4.5, 51) women participants were recruited compared to 171 (IQR: 57, 311.5) men, and 17 (IQR: 7.5, 21.5) racial/minority patients were recruited compared to 241 (IQR: 123, 463.5) White participants. Women represent 16.6% of the disease population, and the median PPR is 0.62 (IQR: 0.42, 0.88), which has remained constant over time (Figure 1). None of the device trials reported outcomes based on sex/gender or race/ethnicity.

CONCLUSIONS

This systematic review highlights the disparities in recruitment and outcome reporting based on sex and race/ethnicity in EVAR device development trials. While most trials may be underpowered to study these differences, recent registry studies show differential outcomes based on sex and race/ethnicity of vascular patients. Therefore, it is imperative to include and report outcomes in these participants, starting from the initial device development phases to improve generalizability of device-use and understand sources of variation in device performance.

Editor's Choice - Endurant Stent Graft in Patients with Challenging Neck Anatomy "One Step Outside Instructions for Use": Early and Midterm Results from the EAGLE Registry

OBJECTIVE

The aim of the Endurant for Challenging Anatomy: Global Experience (EAGLE) registry is to evaluate prospectively the technical and clinical success rate of a stentgraft used in patients with challenging neck anatomy outside the instructions for use (IFU) but within objective anatomical limits.

METHODS

This was a prospective, international, multicentre, observational study. From 1 February 2012 to 1 September 2017, patients with an abdominal aortic aneurysm with a challenging infrarenal neck that were deemed suitable for endovascular aneurysm repair were included prospectively at 23 European centres. Patients were distributed by anatomy into three groups: short neck (SN; infrarenal neck 5 - 10 mm in combination with suprarenal angulation [α] ≤ 45° and infrarenal angulation [β] ≤ 60°); medium neck (MN; infrarenal neck 10 - 15 mm with α ≤ 60° and β 60° - 75° or α 45°- 60° and β ≤ 75°; and long angulated neck (LN; infrarenal neck ≥ 15 mm with α ≤ 75° and β 75°- 90° or α 60°- 75° and β ≤ 90°. All computed tomography scans were reviewed by an independent core laboratory. Primary outcomes were technical and clinical success. Secondary endpoints were peri-operative major adverse events, all cause mortality, aneurysm related mortality, endoleaks, migration, and secondary intervention.

RESULTS

One hundred and fifty patients (81.3% male) were included (SN = 55, MN = 16, LN = 79). The median follow up was 36 ± 12.6 months. In the overall cohort, the technical success rate was 93.3%. Estimated freedom from aneurysm related death was 97.3% at three years. Freedom from secondary interventions was 84.7% at three years. Estimated clinical success was 96.0%, 90.8%, and 83.2% at 30 days, one year, and three years, respectively. Estimated freedom from all cause mortality, late type IA endoleak, and migration at three years was 75.1%, 93.7%, and 99.3%, respectively.

CONCLUSION

The early and midterm results of the EAGLE registry show that endovascular repair with the Endurant stentgraft in selected patients with challenging infrarenal neck anatomy yields results in line with large "real world" registries. Long term results are awaited for more definitive conclusions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Case of bilateral aortoiliac Aneurysm with Persistent aneurysmal Sciatic Artery Treated by Endovascular Aneurysm Repair

Femoral artery is the conventional access for endovascular abdominal aortic aneurysm repair（EVAR）.Patients with an anomalous persistent sciatic artery(PSA) is usually at the expense of an atrophied femoral artery. Therefore, EVAR for patients with PSA anomaly is exceptionally challenging. We report the case of a 69-year-old man with an aortoiliac aneurysm and right PSA. Preoperative computed tomography angiography (CTA) revealed a tortuous infrarenal abdominal aortic aneurysm, bilateral common-internal iliac aneurysms and a right aneurysmal PSA with an ipsilateral atrophic femoral and superficial femoral artery. The aortoiliac aneurysm was successfully repaired through endovascular approach with access through the right persistent sciatic artery，bilateral femoral artery and left brachial artery. 1-month post-operation, CTA revealed a type 1 endoleak originating from the proximal end of the aorta graft. Second and third operation was performed to close the endoleak through extended proximal cuff with chimney bilateral renal stents and sac embolisation with coils and fibrin glue at 1 and 14 months after the first operation. CTA performed three months after the third operation did not show any endoleaks. A persistent sciatic artery can be used as an access for endovascular repair of a complicated infrarenal aortoiliac aneurysm combined with an anomalous persistent sciatic artery and an atrophied femoral artery.

Up to 10-year follow-up after EVAR with the Endurant stent graft system: a single-center experience

BACKGROUND

Endovascular aneurysm repair (EVAR) has become the preferred treatment for infrarenal abdominal aortic aneurysms (AAA) over open surgical repair. The Endurant stent graft is widely used, and large registries report low rates of aneurysm-related mortality and reinterventions at midterm follow-up. Reports of long-term follow-up are limited. The aim of this study is to report our experiences and share our results, reintervention rate and mortality at long-term follow-up after using the Endurant stent graft.

METHODS

All consecutive patients treated between 2009 and 2013 with the Medtronic Endurant I and II stent graft for an infrarenal AAA in an elective setting were included. Primary outcomes were overall and aneurysm-related survival and reintervention rates.

RESULTS

One hundred sixty-five consecutive patients (median age 74; IQR: 68-79) with an aneurysm diameter of 62 mm (IQR: 58-70) and neck length of 29 mm (IQR: 21-40) were electively treated with the Endurant I or II stent graft. One hundred thirty-four patients (81.2%) were treated inside IFU (instructions for use) and 31 (18.8%) outside IFU. At median follow-up of 76 months (IQR: 50-97), 60 patients (36.4%) were deceased. Kaplan-Meier estimates at 10 years follow-up of overall survival and freedom from aneurysm-related mortality were respectively 48.5% (CI: 43.7-53.3%) and 97.3% (CI: 95.7-98.9%). Freedom from reintervention was 86.0% with an CI: 83.1-88.9% at 5 years follow-up and 75.6% with a CI: 70.2-81.0% at 10 years follow-up. A total of 25 (15.2%) patients had an EVAR-related reintervention; indications were endoleak (EL) type 1A (N.=11), EL type 1B (N.=3), EL type 2 (N.=6), EL type 3 (N.=1) and limb occlusion (N.=4). We found no significant differences in outcome between the inside and outside IFU groups. At 5 years follow-up 92.6% of patients had stable or decreased diameter, and 7.4% had an increased diameter.

CONCLUSIONS

This large cohort single-center study demonstrates the effectiveness and safety of the Endurant stent graft system at long-term follow-up with low reintervention rates and aneurysm-related mortality.

Female sex is associated with comparable 5-year outcomes after contemporary endovascular aneurysm repair despite more challenging anatomy

BACKGROUND

Women with abdominal aortic aneurysms less often meet anatomic criteria for endovascular repair and experience worse perioperative and long-term survival.

METHODS

We compared long-term survival, aneurysm-related mortality, and rates of endoleaks and reinterventions between male and female patients in the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) using 2:1 propensity score matching.

RESULTS

There were 1130 male patients and 133 female patients, yielding 399 patients after matching (266 male patients, 133 female patients). Female patients were older, with smaller aneurysms, smaller iliac arteries, and shorter, more angulated necks, and they were more often treated outside the device instructions for use (all P < .001). Through 5 years, female patients experienced overall mortality comparable to that of well-matched male patients (34% vs 38%, respectively; hazard ratio, 0.89 [0.61-1.29]; P = .54) and lower aneurysm-related mortality (0% vs 3%; P = .047). Female patients experienced higher rates of any postoperative type IA endoleak through 5 years (10% vs 1%; P < .001) but comparable rates of secondary endovascular procedures (14% vs 16%; P = .40). Female sex was independently associated with significantly higher risk of long-term type IA endoleaks (hazard ratio, 4.8 [1.2-20.8]; P = .04), even after accounting for anatomic factors. No female patient experienced aneurysm rupture during follow-up, and only one female patient underwent conversion to open repair.

CONCLUSIONS

Despite more challenging anatomy, female patients in the ENGAGE registry had long-term outcomes comparable to those of male patients. However, female patients experienced higher rates of type IA endoleaks. Although standard endovascular aneurysm repair remains a viable solution for most women, whether high-risk patients may be better served with open surgery, custom-made devices, EndoAnchors (Aptus Endosystems, Sunnyvale, Calif), or chimneys is worthy of further study.

Outcomes of using endovascular aneurysm repair with active fixation in complex aneurysm morphology

OBJECTIVE

The ideal treatment option for patients with complex aneurysm morphology remains highly debated. The aim of this study was to investigate the impact of endovascular aneurysm repair (EVAR) with active fixation on outcomes in patients with complex aneurysm morphology.

METHODS

There were 340 consecutive patients who underwent EVAR using active fixation devices, 234 with active infrarenal fixation (AIF; Gore Excluder; W. L. Gore & Associates, Flagstaff, Ariz) and 106 with active suprarenal fixation (ASF; 85 Medtronic Endurant [Medtronic, Santa Rosa, Calif] and 21 Cook Zenith [Cook Medical, Bloomington, Ind]). Demographics, comorbidities, anatomic features, and outcomes were analyzed for patients receiving devices with active fixation. Outcomes of using active fixation in necks with <15-mm neck lengths, >60-degree infrarenal neck angle (β), >30-mm infrarenal neck diameter, severe aortic neck calcification or thrombus, and nonstraight neck morphology were evaluated.

RESULTS

Of the 340 patients, 106 (78 men; mean age, 74.5 ± 9.3 years at the time of surgery) received implants with ASF and 234 (191 men; mean age, 74.6 ± 8.9 years at the time of surgery) received implants with AIF. In comparing AIF and ASF devices, patients in the suprarenal fixation group had significantly shorter follow-up time (25 ± 17 months vs 44.3 ± 32 months; P < .0001). Patients in the ASF group had shorter aortic neck lengths (25.5 ± 15.1 mm vs 28.6 ± 14.9 mm; P = NS) and significantly larger infrarenal neck diameters (25.9 ± 6.3 mm vs 23.4 ± 3.2 mm; P < .0001) and aneurysm diameters (59.9 ± 11.6 mm v. 55.9 ± 10.0 mm; P = .002). Outcomes were similar between groups, with no significant differences in reintervention, proximal endoleak, sac growth, abdominal aortic aneurysm-related death, or rupture. Of the complex anatomic neck features investigated, neck diameter >30 mm and nonstraight neck morphology had the highest rates of reintervention in ASF devices.

CONCLUSIONS

In cases of hostile infrarenal neck morphology, ASF appears to be used more frequently. Our data suggest that ASF may be useful for certain patients but may be unfavorable for others, such as those with wide necks or several difficult neck features. Nevertheless, further research is needed to evaluate more optimal treatment options, such as fenestrated EVAR, branched EVAR, and endovascular adjuncts such as EndoAnchors (Aptus Endosystems, Sunnyvale, Calif), in dealing with high-risk anatomic characteristics that may not be optimally managed with standard EVAR devices with active fixation.

Clinical Outcomes of Endovascular Aneurysm Repair with the Kilt Technique for Abdominal Aortic Aneurysms with Hostile Aneurysm Neck Anatomy: A Korean Multicenter Retrospective Study

PURPOSE

We aimed to evaluate the clinical efficacy and short-term clinical outcomes of Kilt technique-based endovascular aneurysm repair (EVAR) with Seal^® stent-grafts for abdominal aortic aneurysms (AAAs) with hostile neck anatomy (angle > 60°).

MATERIALS AND METHODS

We retrospectively evaluated the pre-EVAR and follow-up computed tomography angiography findings of 24 patients (mean age 71 ± 11 years; age range 32-87 years; mean follow-up 50 ± 12 months) with hostile neck AAAs treated between 2010 and 2015. Serial change in aneurysmal neck angle was calculated using a standardized protocol. Relationships between clinical variables and outcomes were evaluated using univariate and multivariate Cox analyses and mixed-model regression. In addition, the Kaplan-Meier method was used to assess the cumulative rates of survival, endoleak, and reintervention.

RESULTS

The primary technical success rate (success within 24 h after EVAR) was 100% (24/24). The survival rate was 96 ± 8% at 1 month, 6 months, 1 year, and 3 years, and 87 ± 18% at 5 years. Endoleaks occurred in three patients. Four reinterventions were performed in three patients; no surgical revisions were required. Causes of post-EVAR mortality included intracerebral hemorrhage at 14 days and rhabdomyolysis at 32 months. The most remarkable change after Kilt-based EVAR was an acute decrease in the neck angle, which was observed between the pre-EVAR and first follow-up visits (at 1 month) (P = 0.001).

CONCLUSION

Kilt-based EVAR with Seal^® stent-grafts for AAAs with a severely angulated neck (angle > 60°) provided high technical success, low mortality, and low complication rates during short-term follow-up.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Early and Late Endograft Limb Proximal Migration with Resulting Type 1b Endoleak following an EVAR for Ruptured AAA

Introduction. Seal zone failure after EVAR leads to type 1 endoleaks and increases the risk of delayed aortic rupture. Type 1b endoleaks, although rare, represent a true risk to the repair. Case Presentation. We report the case of a 65-year-old female who underwent emergent endovascular repair for a ruptured infrarenal abdominal aortic aneurysm and developed bilateral type 1b endoleaks following proximal migration of both endograft limbs. The right-side failure was diagnosed within 48 hours from the initial repair and the left side at the 1-year follow-up. Both sides were successfully treated with endovascular techniques. A review of the literature with an analysis of potential risk factors is also reported. Conclusion. For patients undergoing EVAR for ruptured AAA and with noncalcified iliac arteries, more aggressive oversizing of the iliac limbs is recommended to prevents distal seal zone failures.

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

PURPOSE

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

TECHNIQUE

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

CONCLUSION

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

Current aortic endografts for the treatment of abdominal aortic aneurysms

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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