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Krisna Pertiwi PF, Sudarma IW, Prana Jagannatha GN, Kosasih AM, Dyah Yustika Dewi CI, Angga Wijaya IGA. Outcomes of advanced EVAR versus open surgery in the management of complex abdominal aortic aneurysm repair: A systematic review and meta-analysis. Asian Cardiovasc Thorac Ann 2024:2184923241262847. [PMID: 38887046 DOI: 10.1177/02184923241262847] [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: 06/20/2024]
Abstract
BACKGROUND Open surgery is still acknowledged as the gold standard for complex abdominal aortic aneurysm (c-AAA). Recently, advanced-endovascular aortic aneurysm repair (EVAR) for c-AAA has been developed, but its effectiveness compared to open surgery is still unclear. METHOD A systematic search was performed on the MEDLINE through PubMed and ScienceDirect databases. The search was aimed to investigate outcomes of both fenestrated- and chimney-EVAR (consider as advanced EVAR) compared to open surgery in c-AAA. Outcomes included postoperative complications, 30-day mortality, long-term mortality, and reintervention rate. Data were collected using the Mantel-Haenszel fixed effects model with relative risk (RR) as the effect size with 95% confidence interval (CI). RESULTS A total of 25 studies (n = 12,845 patients) were included in our study. The results demonstrated that advanced-EVAR correlated with diminished postoperative complications (RR 0.53; 95% CI 0.49-0.57; p < 0.001) compared to open surgery. Advanced-EVAR was associated with lower 30-day mortality compared to open surgery (RR 0.66; 95% CI 0.53-0.82; p < 0.001). Subgroup analysis revealed that fenestrated-EVAR resulted in superior outcomes (p < 0.001), whereas the chimney-EVAR subgroup did not show significant differences (p = 0.79), compared to open surgery in terms of 30-day mortality. Unfortunately, advanced-EVAR was associated with a higher long-term mortality rate (RR 1.46; 95% CI 1.20-1.78; p < 0.001) and a higher reintervention rate (RR 1.26; 95% CI 1.01-1.59; p = 0.04) compared to open surgery. CONCLUSION Advanced EVAR, especially fenestrated-EVAR, presented better short-term outcomes compared to open surgery; however, it failed to demonstrate superiority over open surgery in improving long-term outcomes.
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Affiliation(s)
- Putu Febry Krisna Pertiwi
- Faculty of Medicine, Udayana University/Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | - I Wayan Sudarma
- Cardiothoracic and Vascular Surgery Division, Department of Surgery, Faculty of Medicine, Udayana University, Indonesia/Prof. Dr I.G.N.G. Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | | | - Anastasya Maria Kosasih
- Faculty of Medicine, Udayana University/Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | | | - I Gusti Agung Angga Wijaya
- Faculty of Medicine, Udayana University/Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Bali, Indonesia
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Chen Y, Wang X, Bi J, Liu Z, Niu F, Zhang X, Dai X. Comparative clinical study of short-term outcomes between table fenestrated and chimney endovascular aneurysm repair for hostile neck aneurysms. Vascular 2024; 32:273-280. [PMID: 36305329 DOI: 10.1177/17085381221135859] [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: 02/18/2024]
Abstract
OBJECTIVES Hostile neck abdominal aortic aneurysm (AAA) is challenging for standard endovascular aneurysm repair (EVAR). We sought to compare fenestrated endovascular aneurysm repair (fEVAR) and chimney endovascular aneurysm repair (chEVAR) for hostile neck AAA. METHODS Patients were identified retrospectively. Hostile neck anatomy was defined as a proximal neck length of <15 mm or angulation >60°. The choice of fEVAR or chEVAR was based on neck anatomy and physician preference. Type I endoleak (T1EL) was the primary outcome. Other outcomes included type III endoleak (T3EL), visceral stent occlusion, renal insufficiency, reintervention, and mortality. RESULTS A total of 84 patients were included from April 2012 to December 2021. fEVAR and chEVAR patients were 48 and 36 cases, respectively. Both groups showed similar rate of T1EL, T3EL, visceral stent occlusion, renal insufficiency, reintervention, and mortality. However, chEVAR patients had a more tortuous neck (61.1% vs. 16.7%, p < 0.001), while fEVAR patients had a greater neck size (29.5 ± 6.3 mm vs. 24.5 ± 4.8 mm, p < 0.001) and more reconstructing target arteries (2.2 ± 1.1 vs 1.3 ± 0.6, p < 0.001). CONCLUSIONS fEVAR and chEVAR show similar safe and effective outcomes in well-selected hostile neck. fEVAR might be able to reconstruct multiple visceral arteries, and chEVAR seems justified in patients with poor anatomical suitability for fEVAR.
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Affiliation(s)
- Yonghui Chen
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xuguang Wang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Vascular Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region, China
| | - Jiaxue Bi
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Zongwei Liu
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Fang Niu
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaoxing Zhang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiangchen Dai
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
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Bizos A, Hostalrich A, Chaufour X, Desgranges P, Layese R, Cochennec F, Canoui-Poitrine F. Comparison of Fenestrated Stentgrafts and Open Repair for Juxtarenal Aortic Aneurysms Using a Propensity Score Matching. Ann Vasc Surg 2023; 95:50-61. [PMID: 37270093 DOI: 10.1016/j.avsg.2023.05.031] [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: 01/18/2023] [Revised: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND The purpose of this study was to compare postoperative morbi-mortality and medium-term follow-up of fenestrated stent grafting and open repair (OR) for patients with juxtarenal aortic aneurysms (JRAAs). METHODS All consecutive patients who underwent custom-made fenestrated endovascular aortic repair (FEVAR) or OR for complex abdominal aortic aneurysm between 2005 and 2017 in 2 tertiary centers were scrutinized. Patients with JRAA constituted the study group. Suprarenal and thoracoabdominal aortic aneurysms were excluded. The groups were made comparable through the use of a propensity score matching. RESULTS 277 patients with JRAAs were included, 102 (36.8%) in the FEVAR group and 175 (63.2%) in the OR group, respectively. After propensity score matching, 54 FEVAR patients (52.9%) and 103 OR patients (58.9%) were included for analysis. In-hospital mortality rates were 1.9% (n = 1) in the FEVAR group versus 6.9% (n = 7) in the OR group (P = 0.483). Postoperative complications were less common in the FEVAR group (14.8% vs. 30.7%; P = 0.033). Mean follow-up was 42.1 months in the FEVAR group and 40 months in the OR group. Overall mortality rates at 12 and 36 months were 11.5% and 24.5% in the FEVAR group versus 9.1 % (P = 0.691) and 11.6% (P = 0.067) in the OR group. Late reinterventions were more frequent in the FEVAR group (11.3% vs. 2.9%; P = 0.047). However, freedom from reintervention rates were not significantly different at 12 months (FEVAR: 86% vs. OR: 90%; P = 0.560) and 36 months (FEVAR: 86% vs. OR: 88.4%, P = 0.690). In the FEVAR group, persistent endoleak during follow-up was identified in 11.3% of cases. CONCLUSIONS In the present study, there was no statistical difference in terms of mortality in-hospital at 12 or 36 months between FEVAR and OR groups for JRAA. FEVAR for JRAA was associated with a significant reduction of overall postoperative major complications compared with OR. There were significantly more late reinterventions in the FEVAR group.
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Affiliation(s)
- Alia Bizos
- Department of Vascular Surgery, Rangueil University Hospital, Toulouse, France.
| | - Aurélien Hostalrich
- Department of Vascular Surgery, Rangueil University Hospital, Toulouse, France
| | - Xavier Chaufour
- Department of Vascular Surgery, Rangueil University Hospital, Toulouse, France
| | - Pascal Desgranges
- Department of Vascular Surgery, Henri-Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Richard Layese
- Department of Vascular Surgery, Henri-Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Frédéric Cochennec
- Department of Vascular Surgery, Henri-Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
| | - Florence Canoui-Poitrine
- Department of Vascular Surgery, Henri-Mondor University Hospital (Assistance Publique-Hopitaux de Paris - APHP), Créteil, France
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Zhou Y, Wang J, He H, Li Q, Li M, Li X, Shu C. Comparative Effectiveness of Treatment Modalities for Complex Aortic Aneurysms: A Network Meta-Analysis of Observational Studies. Ann Vasc Surg 2023:S0890-5096(23)00123-1. [PMID: 36868464 DOI: 10.1016/j.avsg.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/28/2023] [Accepted: 02/19/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND To conduct a network meta-analysis comparing multiple treatments for complex aortic aneurysms (CAAs). METHODS Medical databases were searched on November 11, 2022. Twenty-five studies (5,149 patients) and four treatments (open surgery [OS], chimney/snorkel endovascular aneurysm repair [CEVAR], fenestrated endovascular aneurysm repair [FEVAR], and branched endovascular aneurysm repair) were selected. Outcomes were branch vessel patency, mortality, and reintervention at short- and long-term followup, and perioperative complications. RESULTS Regarding branch vessel patency, OS was the most effective treatment and had higher 24-month branch vessel patency rates than CEVAR (odds ratio [OR], 10.77; 95% confidence interval [CI], 2.08-55.79). FEVAR (OR, 0.52; 95% CI, 0.27-1.00) and OS (OR, 0.39; 95% CI, 0.17-0.93) were better than CEVAR regarding 30-day mortality and 24-month mortality, respectively. Regarding 24-month reintervention, OS was better than CEVAR (OR, 3.07; 95% CI, 1.15-8.18) and FEVAR (OR, 2.48; 95% CI, 1.08-5.73). Regarding perioperative complications, FEVAR had lower acute renal failure rates than OS (OR, 0.42; 95% CI, 0.27-0.66) and CEVAR (OR, 0.47; 95% CI, 0.25-0.92) and lower myocardial infarction rates than OS (OR, 0.49; 95% CI, 0.25-0.97) and was the most effective treatment in preventing acute renal failure, myocardial infarction, bowel ischemia, and stroke, while OS was the most effective treatment in preventing spinal cord ischemia. CONCLUSIONS OS might have advantages regarding branch vessel patency, 24-month mortality, and reintervention and is similar to FEVAR regarding 30-day mortality. Regarding perioperative complications, FEVAR might confer advantages in preventing acute renal failure, myocardial infarction, bowel ischemia, and stroke, and OS in preventing spinal cord ischemia.
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Affiliation(s)
- Yang Zhou
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China; Vascular Disease Institute of Central South University, Changsha, Hunan, China
| | - Junwei Wang
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China; Vascular Disease Institute of Central South University, Changsha, Hunan, China
| | - Hao He
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China; Vascular Disease Institute of Central South University, Changsha, Hunan, China
| | - Quanming Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China; Vascular Disease Institute of Central South University, Changsha, Hunan, China
| | - Ming Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China; Vascular Disease Institute of Central South University, Changsha, Hunan, China
| | - Xin Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China; Vascular Disease Institute of Central South University, Changsha, Hunan, China
| | - Chang Shu
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China; Vascular Disease Institute of Central South University, Changsha, Hunan, China; Department of Vascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
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Rastogi V, Marcaccio CL, Kim NH, Patel PB, Anjorin AC, Zettervall SL, Patel VI, de Bruin JL, Verhagen HJM, Schermerhorn ML. The effect of supraceliac versus infraceliac landing zone on outcomes following fenestrated endovascular repair of juxta-/pararenal aortic aneurysms. J Vasc Surg 2023; 77:9-19.e2. [PMID: 35981657 PMCID: PMC9789162 DOI: 10.1016/j.jvs.2022.08.007] [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: 04/27/2022] [Revised: 07/29/2022] [Accepted: 08/05/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE With increasing experience in fenestrated endovascular aneurysm repair (FEVAR) over time, devices designed to treat juxta-/pararenal aortic aneurysms have evolved in complexity to extend to more proximal landing zones and incorporate more target vessels. We assessed perioperative outcomes in patients who underwent juxta-/pararenal FEVAR with supraceliac vs infraceliac sealing in the Vascular Quality Initiative. METHODS We identified all patients who underwent elective FEVAR (commercially available FEVAR and physician-modified endografts) for juxta-/pararenal aortic aneurysms in the Vascular Quality Initiative between 2014 and 2021. Supraceliac sealing was defined as proximal sealing in aortic zone 5, or zone 6 with a celiac scallop/fenestration/branch or celiac occlusion. Primary outcomes were perioperative and 3-year mortality. Secondary outcomes included completion endoleaks, in-hospital complications, and factors associated with 3-year mortality. We calculated propensity scores and used inverse probability-weighted Cox regression and logistic regression modeling to assess outcomes. RESULTS Among 1486 patients identified, 1246 patients (84%) underwent infraceliac sealing, and 240 patients (16%) underwent supraceliac sealing. Of the supraceliac patients, 74 (31%) had a celiac scallop, 144 (60%) had a celiac fenestration/branch, and 22 (9.2%) had a celiac occlusion (intentional or unintentional). After risk-adjusted analyses, there were no differences in perioperative mortality following supraceliac sealing compared with infraceliac sealing (2.3% vs 2.5%; hazard ratio [HR], 0.67; 95% confidence interval [CI], 0.26-1.8; P = .42), or 3-year mortality (12% vs 15%; HR, 0.89; 95% CI, 0.53-1.5; P = .67). Compared with infraceliac sealing, supraceliac sealing was associated with lower odds of type-IA completion endoleaks (odds ratio [OR], 0.24; 95% CI, 0.05-0.67), but higher odds of any complication (12% vs 6.9%; OR, 1.6; 95% CI, 1.01-2.5) including cardiac complications (5.5% vs 1.9%; OR, 2.6; 95% CI, 1.3-5.1), lower extremity ischemia (3.0% vs 0.9%; OR, 3.2; 95% CI, 1.02-9.5), and acute kidney injury (16% vs 11%; OR, 1.6; 95% CI, 1.05-2.3). Though non-significant, there was a trend towards higher risk of spinal cord ischemia following supraceliac sealing compared with infraceliac sealing (1.7% vs 0.8%; OR, 2.2; 95% CI, 0.70-6.4). There were no differences in bowel ischemia between groups (1.7% vs 1.5%; OR, 0.83; 95% CI, 0.24-1.23). A more proximal aneurysm disease extent was associated with higher 3-year mortality (HR zone 8 vs 9, 1.7; 95% CI, 1.1-2.5), whereas procedural characteristics had no influence. CONCLUSIONS Compared with sealing at an infraceliac level, supraceliac sealing was associated with lower risk of type IA endoleaks and similar mortality. However, clinicians should be aware that supraceliac sealing was associated with higher perioperative morbidity. Future studies with longer follow-up are needed to adequately assess durability differences to comprehensively weigh the risks and benefits of utilizing a higher sealing zone within the visceral aorta for juxta-/pararenal FEVAR.
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Affiliation(s)
- Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Nicole H Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Aderike C Anjorin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, New York, NY
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Camazine M, Kruse RL, Bath J, Singh P, Vogel TR. 30-Day Readmission and Outcomes after Fenestrated versus Traditional Endovascular Aortic Aneurysm Repair. Ann Vasc Surg 2022; 85:314-322. [PMID: 35339596 DOI: 10.1016/j.avsg.2022.03.016] [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: 12/08/2021] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Fenestrated endovascular aneurysm repair (FEVAR) has emerged as a minimally invasive alternative for repairing complex abdominal aortic aneurysms (AAA). Comparisons of outcomes for FEVAR and traditional endovascular aneurysm repair (EVAR) are limited. We evaluated outcomes following elective endovascular AAA repair with FEVAR or EVAR. METHODS Hospitalizations for elective nonruptured AAA repair from 2014-2016 were selected from the Nationwide Readmissions Database (NRD) using ICD-9 and ICD-10 procedure and diagnosis codes. In-hospital mortality, length of stay (LOS), complications, 30-day readmission, and charges were evaluated. Multivariable logistic regression was used to control for confounding between groups. RESULTS We identified 23,262 EVAR and 2,373 FEVAR with nonruptured elective procedures. In-hospital mortality was 0.14% for both groups (p=.99). Of those at risk for readmission (21,152 EVAR, 1,915 FEVAR), index LOS was greater for FEVAR compared to EVAR, 1.8 days vs. 1.7 days (p=0.028). There was no difference in procedure type based on hospital location (p=0.37), teaching status (p=0.17) or hospital size (p=0.26). During the index hospitalization, pneumonia, renal, and respiratory complications were similar between groups (all p>0.05). FEVAR patients were more likely to experience cardiac complications (p=0.0098) or hemorrhage (p=0.029). Total charges for the index stay were greater for FEVAR compared to EVAR ($125,381 vs. $113,513, p<.0001). All-cause 30-day readmission was similar between groups (7.0% EVAR vs. 8.0% FEVAR, p=0.37), as were time to readmission (11.9 vs. 13.3 days, p=0.16) and readmission charges ($53,967 vs $56,617, p=0.75). Renal failure was the most common readmission stay complication, with similar rates for EVAR and FEVAR patients (p=0.22). Pneumonia was a more common complication during the readmission stay for EVAR patients (p=0.004). Renal disease and chronic pulmonary disease were the most common comorbidities in the readmission stay for both groups. CONCLUSION For patients with nonruptured elective AAA , FEVAR was not associated with increased mortality, length of stay, readmission, or most complications compared to traditional EVAR. Despite increased technical complexity of cannulating and stenting visceral arteries with FEVAR, these data demonstrate that FEVAR carries similar risk of renal, respiratory, and infectious complications compared to traditional EVAR. FEVAR patients were more likely to experience hemorrhagic and cardiac complications during the index hospitalization. EVAR patients were more likely to have pneumonia during readmission. Overall risk for readmission after endovascular aortic repair was associated with female sex, greater age, chronic pulmonary disease, malignancy, and loss of function. Further investigation into causes and prevention of 30-day readmissions are needed for both procedures.
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Affiliation(s)
- Maraya Camazine
- Division of Vascular Surgery, Department of Surgery, University of Missouri, School of Medicine, Columbia, MO
| | - Robin L Kruse
- Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, MO
| | - Jonathan Bath
- Division of Vascular Surgery, Department of Surgery, University of Missouri, School of Medicine, Columbia, MO
| | - Priyanka Singh
- Division of Vascular Surgery, Department of Surgery, University of Missouri, School of Medicine, Columbia, MO
| | - Todd R Vogel
- Division of Vascular Surgery, Department of Surgery, University of Missouri, School of Medicine, Columbia, MO.
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Nada A, Fakhr M, Elwakad M, Ali M. A Finite Element Based Analysis of a Hemodynamics Efficient Flow Stent Suitable for Different Abdominal Aneurysm Shapes. J Biomech Eng 2022; 144:1137925. [PMID: 35237800 DOI: 10.1115/1.4053999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Indexed: 11/08/2022]
Abstract
This research aimed to examine the impact of a proposed flow stent (PFS) on different abdominal artery shapes. For that purpose, a finite element-based model using the computational fluid dynamics (CFD) method is developed. The effect of PFS intervention on the hemodynamic efficiency is estimated by all of the significant criteria used for the evaluation of aneurysm occlusion and possible rupture; the flow velocity, pressure, wall shear stress (WSS), and WSS-related indices. Results showed that PFS intervention preserves the effects of high flow rate and decreases irregular flow recirculation in the sac of the aneurysm. The flow velocity decreases inside the aneurysm sac in the range of 55% to 80%. The time-averaged wall shear stress (TAWSS) was reduced from 42% to 53% by FPS deployment. The simulation results implies that PFS could heal an aneurysm efficiently with a mechanism that causes the development of thrombus and ultimately leads to aneurysm resorption.
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Affiliation(s)
- Ayat Nada
- Department of Computers and Systems, Electronics Research Institute, Cairo, Egypt
| | - Mahmoud Fakhr
- Department of Computers and Systems, Electronics Research Institute, Cairo, Egypt
| | - Mohamed Elwakad
- Department of Biomedical Engineering, Faculty of Engineering & Technology, Future University, Cairo, Egypt
| | - Mohamed Ali
- Department of Biomedical Engineering, Faculty of Engineering, Helwan University, Cairo, Egypt
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Siada S, Malgor EA, Al-Musawi M, Giannopoulos S, Jacobs DL, Malgor RD. Iliac Artery Endoconduits Should be the Preferred Adjunctive Access Procedure to Facilitate Complex Endovascular Aortic Aneurysm Repair. Vasc Endovascular Surg 2022; 56:376-384. [PMID: 35200054 DOI: 10.1177/15385744211037616] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Iliac artery anatomy can have a dramatic impact on the success of endovascular complex aortic aneurysm (CAA) procedures as endograft delivery systems need to be advanced and manipulated through these access vessels. The aim of this study was to evaluate the outcomes of iliac artery conduits with emphasizes on open vs endovascular conduits performed to facilitate CAA endovascular repair. METHODS All patients who had open or endovascular iliac conduits prior to endovascular CAA repair to treat thoracoabdominal, juxtarenal, or suprarenal aneurysms at the University of Colorado Hospital from January 2009 through January 2019 were included. Patients who presented with symptomatic or ruptured aortic aneurysms were excluded. Outcomes of interest included postoperative complications and mortality in patients undergoing iliac conduits. RESULTS Twenty-seven patients with a total of 42 conduits were included in the study. The majority of patients (N = 15, 56%) were female and the average age was 72 ± 9 years. The calculated VQI cardiac index was .6% (range, .3%-.8%). Eighteen (43%) endovascular and 24 (57%) open iliac conduits were performed during the study period. Thirty (71%) conduits were performed in a staged fashion, while 12 (29%) were performed at the same time as endovascular CAA repair. The mean time between conduit and definitive aneurysm repair surgery was 130 ± 68 days in the endovascular and 107 ± 79 days in the open groups (P = .87). No aneurysm rupture occurred during the staging period in either group. The median follow-up for the entire cohort was 18 ± 22 months. The median length of hospital stay for patients undergoing endovascular and open ICs was 6 (ranging, 1-28 days) and 7 days (ranging, 3-18 days), respectively. Patients undergoing open conduits had significantly more complications than those undergoing endovascular conduit (endoconduit) creation. A total of 4 (15%) patients died within 30 days after aneurysm repair. Out of 23 survivors, 18 (78%) patients were discharged home, 4 (18%) patients were discharged to a skilled nursing facility, and 1 (4%) patient was discharged to an acute rehabilitation facility. No mortality difference based on type of conduit was found. CONCLUSIONS Overall complication rate associated with creation of open iliac artery conduits is not negligible. Endoconduits, which carry less morbidity than open conduits, are preferred as a first-line adjunctive access procedure to facilitate complex endovascular aortic aneurysm repair.
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Affiliation(s)
- Sammy Siada
- Division of Vascular Surgery, University of California at Fresno, Fresno, CA, USA
| | - Emily A Malgor
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
| | - Mohammed Al-Musawi
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Donald L Jacobs
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
| | - Rafael D Malgor
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
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Rastogi V, de Bruin JL, Varkevisser RRB, Oliveira NFG, Bouwens E, Hoeks SE, Raa ST, Josee van Rijn M, Goncalves FB, Schermerhorn ML, Fioole B, Verhagen HJM. Proximal Seal Dilatation following Fenestrated Endovascular Repair for Complex Abdominal Aortic Aneurysms. J Vasc Surg 2022; 75:1521-1529.e1. [PMID: 34990782 DOI: 10.1016/j.jvs.2021.12.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/10/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Although Proximal neck dilatation following infrarenal endovascular aneurysm repair (EVAR) is common and is associated with proximal graft failure, little is known about sealing zone dilatation and its clinical relevance following fenestrated EVAR (FEVAR). We studied proximal seal dilatation (PSD) dynamics following FEVAR and assessed its clinical significance. METHODS We included all consecutive patients treated for a juxta-/supra-renal aneurysm with fenestrated EVAR using the Zenith Fenestrated Endovascular Graft (Cook Medical, Bloomington, Ind) from 2008 to 2018 in two large teaching hospitals in the Netherlands. The primary outcome was PSD over time and was determined using a linear mixed-effects model. Secondary outcomes included associations for early PSD and difference in aortic dilatation at the level of the covered-stent compared to the bare-stent. Proximal seal related adverse events were also obtained. RESULTS Our cohort included 84 patients with a median CTA follow-up time of 24.5 months [IQR 17-42]. Maximum aneurysm-diameter was 60.1 mm (IQR 56.9-67.2). Mean proximal seal diameter at baseline was 26.2 mm (±2.8), mean stent oversizing was 20.1% (±9.1), and mean proximal seal length was 29.5 mm (±11.7). Proximal seal dilatation of 1.7 mm (95%CI:1.4-2.1) was found in the first year, decelerating thereafter (2nd-year: 0.9mm/year [95%CI:0.7-1.1]). Over 10% PSD at one year occurred in 22 patients (27%) and was associated with stent-graft oversizing (OR: 1.1 [95%CI:1.03-1.2], p=.008) and a lower number of target vessels (four fenestrations/ref two fenestrations: OR: 0.13 [95%CI:0.02-0.74], p=.029). At last available imaging, dilatation difference was higher at the level of the covered stent compared with the bare stent (3.0mm [IQR 1.3-5.1] vs. 1.6mm [IQR 0.8-2.5], p<.001). During the study period, only one patient (1.2%) developed a proximal seal related-adverse event (type-IA endoleak). CONCLUSION PSD is present following FEVAR, occurring at a faster rate in the first year and subsequently decelerating thereafter, similarly to neck dilatation after standard infrarenal EVAR. Although its clinical implication seems to remain limited in the first years following implantation, further research is required to assess the effect of PSD on long-term FEVAR outcomes.
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Affiliation(s)
- Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Rens R B Varkevisser
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nelson F G Oliveira
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands; 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
| | - Elke Bouwens
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sanne E Hoeks
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sander Ten Raa
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marie Josee van Rijn
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Frederico Bastos Goncalves
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital Rotterdam, The Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
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10
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D'Oria M, Wanhainen A, Lindström D, Tegler G, Mani K. Pre-Operative Moderate to Severe Chronic Kidney Disease is Associated with Worse Short-Term and Mid-Term Outcomes in Patients Undergoing Fenestrated-Branched Endovascular Aortic Repair. Eur J Vasc Endovasc Surg 2021; 62:859-868. [PMID: 34716095 DOI: 10.1016/j.ejvs.2021.08.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 08/10/2021] [Accepted: 08/26/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To review experience of fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal/thoraco-abdominal aortic aneurysms (PRAA/TAAA) and to assess the association between pre-operative moderate to severe chronic kidney disease (CKD) and post-operative outcomes. METHODS All consecutive patients undergoing (elective and non-elective) F-BEVAR at a single centre (1 January 2011 - 1 July 2019) were identified. Renal function was calculated as the estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease formula. Accordingly, presence of moderate to severe CKD was defined as eGFR < 60 mL/min/1.73m2. RESULTS Overall, 202 consecutive patients (mean age 72 ± 8 years; 25% women) underwent F-BEVAR for the treatment of PRAA/TAAA during the study period. Of these, 51 had a history of moderate to severe CKD (none on chronic haemodialysis). No statistically significant differences were found in demographics and major comorbidities between patients with or without a history of CKD. The overall peri-operative mortality rate was 2%, without statistically significant differences between study groups (p = .26). Patients with prior CKD had statistically significantly higher rates of acute kidney injury (AKI) (37% vs. 12%, p < .001). At three years, overall survival was statistically significantly lower in patients with history of CKD compared with those without pre-operative CKD (57% vs. 82%, p = .010). Similarly, freedom from renal function decline at three years was statistically significantly poorer in patients with prior history of CKD compared with those without pre-operative CKD (43% vs. 80%, p = .020). In a multivariable analysis CKD was independently associated with higher odds of peri-operative AKI (OR 2.8, 95% CI 1.9 - 5.8, p = .030), renal function decline (OR 4.9, 95% CI 1.7 - 9.2, p = .003), and all cause mortality (HR 3.2, 95% CI 1.2 - 8.6, p = .020). CONCLUSION Despite low peri-operative mortality rates that are comparable to patients with unimpaired renal function, occurrence of AKI was statistically significantly higher in subjects with pre-existing moderate to severe CKD. History of CKD was independently associated to renal function decline and poorer midterm survival.
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MESH Headings
- Aged
- Aged, 80 and over
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Aortic Aneurysm, Abdominal/mortality
- Aortic Aneurysm, Abdominal/surgery
- Aortic Aneurysm, Thoracic/diagnostic imaging
- Aortic Aneurysm, Thoracic/mortality
- Aortic Aneurysm, Thoracic/surgery
- Blood Vessel Prosthesis
- Blood Vessel Prosthesis Implantation/adverse effects
- Blood Vessel Prosthesis Implantation/instrumentation
- Blood Vessel Prosthesis Implantation/mortality
- Disease Progression
- Endovascular Procedures/adverse effects
- Endovascular Procedures/instrumentation
- Endovascular Procedures/mortality
- Female
- Glomerular Filtration Rate
- Humans
- Kidney/physiopathology
- Male
- Middle Aged
- Prosthesis Design
- Renal Insufficiency, Chronic/diagnosis
- Renal Insufficiency, Chronic/mortality
- Renal Insufficiency, Chronic/physiopathology
- Retrospective Studies
- Risk Assessment
- Risk Factors
- Severity of Illness Index
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Mario D'Oria
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
| | - Anders Wanhainen
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - David Lindström
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Gustaf Tegler
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Division of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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11
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Marcaccio CL, Zettervall SL, Wu WW, Schermerhorn ML, Wyers MC. Endovascular Snare Facilitates Difficult Transfemoral Target Vessel Cannulation During Fenestrated and Branched Endovascular Aortic Aneurysm Repair. Ann Vasc Surg 2021; 77:338-342. [PMID: 34464731 DOI: 10.1016/j.avsg.2021.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 04/17/2021] [Accepted: 05/01/2021] [Indexed: 10/20/2022]
Abstract
We developed a novel technique using an endovascular snare system to stabilize target vessel cannulation via transfemoral access during fenestrated and branched endovascular aortic aneurysm repair (FBEVAR) in patients with challenging target vessel anatomy. This technique uses a snare, an outer sheath, and an inner delivery sheath to facilitate target vessel cannulation and stenting during FBEVAR. With the outer sheath positioned in the lower end of the partially deployed aortic graft and the delivery sheath within, a large snare is advanced through the outer sheath and over the outside of the delivery sheath until it reaches the curved portion of the delivery sheath at the level of the target vessel. The snare is then tightened to provide stability and maintain proper curvature and alignment of the delivery sheath while the target vessel is selected and stented. Following successful passage, the snare is loosened and removed from the body via the outer sheath. This snare technique is a simple, effective, and inexpensive tool that can be used for difficult target vessel cannulation during FBEVAR.
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Affiliation(s)
- Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Winona W Wu
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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12
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Manunga J, Jordano L, Mirza AK, Teng X, Skeik N, Eisenmenger L. Clinical application and technical details of cook zenith devices modification to treat urgent and elective complex aortic aneurysms. CVIR Endovasc 2021; 4:44. [PMID: 34061297 PMCID: PMC8167926 DOI: 10.1186/s42155-021-00233-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 05/12/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose To describe technical details of modifying four different Cook Zenith devices to treat complex aortic aneurysms. Material In the first three cases, the modification process involved complete stent graft deployment on a sterile back table. Fenestrations were created using an ophthalmologic cautery and reinforced with a radiopaque snare using a double-armed 4–0 Ethibond locking suture based on measurements obtained on centerline of flow. In each instance, a nitinol wire was withdrawn and redirected through and through the fabric and used as a constraining wire. In the fourth patient, modification involved partial stent graft deployment and creation of additional two fenestrations to accommodate renal arteries. The devices are resheathed and implanted in the standard fashion. Results Four patients underwent exclusion of their aneurysms, including thoracoabdominal aneurysms (n = 2), a contained ruptured juxtarenal aneurysm (n = 1), and a ruptured failed previous endovascular repair (n = 1). Fifteen fenestrations were successfully bridged with Atrium iCAST stent grafts. Average graft modification time, operative time, contrast volume, radiation dose, estimated blood loss, and hospital length of stay were 89 min, 155.25 min, 58.8 mL, 2451 mGy, 175 mL, and 4.3 days, respectively. One patient required a secondary intervention to treat a type Ib endoleak. During an average follow-up of 25 months, aneurysm sacs progressively shrank without additional intervention. Conclusion Physician-modified fenestrated/branched endografts are a safe alternative to custom made devices, especially in urgent cases and should be part of the armamentarium of any complex aortic program.
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Affiliation(s)
- Jesse Manunga
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, 920 E 28th Street, Ste 300, Minneapolis, MN, 55407, USA. .,Minneapolis Heart Institute foundation, University of Wisconsin at Madison, Minneapolis, MN, USA.
| | - Lia Jordano
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, 920 E 28th Street, Ste 300, Minneapolis, MN, 55407, USA
| | - Aleem K Mirza
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, 920 E 28th Street, Ste 300, Minneapolis, MN, 55407, USA.,Minneapolis Heart Institute foundation, University of Wisconsin at Madison, Minneapolis, MN, USA
| | - Xiaoyi Teng
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, 920 E 28th Street, Ste 300, Minneapolis, MN, 55407, USA.,Minneapolis Heart Institute foundation, University of Wisconsin at Madison, Minneapolis, MN, USA
| | - Nedaa Skeik
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, 920 E 28th Street, Ste 300, Minneapolis, MN, 55407, USA.,Minneapolis Heart Institute foundation, University of Wisconsin at Madison, Minneapolis, MN, USA
| | - Laura Eisenmenger
- Department of Radiology, Division of neuroradiology, University of Wisconsin at Madison, Madison, USA
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13
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Pomy BJ, Rosenfeld ES, Lala S, Lee KB, Sparks AD, Amdur RL, Ricotta JJ, Sidawy AN, Macsata RA, Nguyen BN. Fenestrated Endovascular Aneurysm Repair Affords Fewer Renal Complications than Open Surgical Repair for Juxtarenal Abdominal Aortic Aneurysms in Patients with Chronic Renal Insufficiency. Ann Vasc Surg 2021; 75:349-357. [PMID: 33831525 DOI: 10.1016/j.avsg.2021.03.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/12/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Although fenestrated endovascular aneurysm repair (FEVAR) has been associated with lower morbidity and mortality than open surgical repair (OSR) in juxtarenal aneurysms (JAAA), there is a paucity of data in the literature comparing outcomes of the approaches specifically in patients with chronic renal insufficiency (CRI). We hypothesized that benefits of FEVAR over OSR observed in the general patient population may be diminished in CRI patients due to their heightened vulnerability to renal dysfunction stemming from contrast-induced nephropathy. This study compares 30-day outcomes between FEVAR and OSR for JAAA in patients with non-dialysis dependent CRI. METHODS All adults with estimated glomerular filtration rate (eGFR) < 60 mL/min (but not requiring dialysis) undergoing elective, non-ruptured JAAA repairs were identified in the American College of Surgeons - National Surgical Quality Improvement (ACS-NSQIP) Targeted EVAR and AAA databases from 2012-2018. JAAA were identified by recorded proximal aneurysm extent. FEVAR patients were identified in the Targeted EVAR database as those receiving the "Cook Zenith Fenestrated" endograft. OSR cases were defined as those that required proximal clamp positions "above one renal" or "between SMA & renals." Infra-renal or supra-celiac proximal clamp placement, or cases involving concomitant renal/visceral revascularization were excluded. Thirty-day outcomes including mortality, major adverse cardiovascular events (MACE), pulmonary, and renal complications were compared between FEVAR and OSR groups. RESULTS There were 284 patients with CRI who underwent elective repair of JAAA (FEVAR: 89; OSR: 195). FEVAR patients were significantly older than those undergoing OSR (77.3±7.2 vs. 74.2±7.7, P=0.001) and less likely to be smokers (25.8% vs 42.1%; P = 0.009). Other baseline demographic and pre-operative parameters were comparable between the two groups.Multivariable analysis revealed no significant difference between FEVAR and OSR in 30-day mortality (4.5% vs 4.6%; OR=1.22; 95% CI=0.35 - 4.22; P=0.753) or unplanned re-operation (4.5% vs 5.1%; OR=0.78; 95% CI=0.22 - 2.70; P=0.693). Patients undergoing FEVAR had significantly fewer pulmonary complications (3.4% vs 18.5%; OR=0.12; 95% CI=0.03 - 0.42; P<0.001) and renal dysfunction (3.4% vs 11.8%; OR 0.24 95% CI=0.07 - 0.86; P=0.029) compared to OSR. FEVAR was also associated with significantly shorter ICU and hospital lengths of stay (ICU stay: 0 days vs 3 days, P<0.0001; hospital stay: 3 days vs 8 days, P<0.0001). CONCLUSION For patients with chronic renal insufficiency, FEVAR offered improved perioperative renal morbidity compared to OSR without a corresponding mortality benefit. Future studies will be required to determine long term outcomes of this procedure in this vulnerable population.
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Affiliation(s)
- Benjamin J Pomy
- The George Washington University Department of Surgery, Washington, District of Columbia.
| | - Ethan S Rosenfeld
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Salim Lala
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - K Benjamin Lee
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Andrew D Sparks
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Richard L Amdur
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - John J Ricotta
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Anton N Sidawy
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Robyn A Macsata
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Bao-Ngoc Nguyen
- The George Washington University Department of Surgery, Washington, District of Columbia
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14
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Rosenfeld ES, Macsata RA, Lala S, Lee KB, Pomy BJ, Ricotta JJ, Sparks AD, Amdur RL, Sidawy AN, Nguyen BN. Open surgical repair of juxtarenal abdominal aortic aneurysms in the elderly is not associated with increased thirty-day mortality compared with fenestrated endovascular grafting. J Vasc Surg 2020; 73:1139-1147. [PMID: 32919026 DOI: 10.1016/j.jvs.2020.08.121] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 08/04/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Endovascular repair of juxtarenal abdominal aortic aneurysms (JAAAs) with fenestrated grafts (fenestrated endovascular aneurysm repair [FEVAR]) has been reported to decrease operative mortality and morbidity compared with open surgical repair (OSR). However, previous comparisons of OSR and FEVAR have not necessarily included patients with comparable clinical profiles and aneurysm extent. Although FEVAR has often been chosen as the first-line therapy for high-risk patients such as the elderly, many patients will not have anatomy favorable for FEVAR. At present, a paucity of data has examined the operative outcomes of OSR in elderly patients for JAAAs relative to FEVAR. Therefore, we chose to perform a propensity-matched comparison of OSR and FEVAR for JAAA repair in patients aged ≥70 years. METHODS Patients aged ≥70 years who had undergone elective nonruptured JAAA repairs from 2012 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted endovascular aneurysm repair (EVAR) and AAA databases. Patients who had undergone FEVAR were identified in the targeted EVAR database as those who had received the Cook Zenith Fenestrated endograft (Cook Medical, Bloomington, Ind). Because our study specifically examined JAAAs, those patients who had undergone OSR with supraceliac proximal clamping or concomitant renal/visceral revascularization were excluded. A 1:1 propensity-match algorithm matched the OSR and FEVAR patients by preoperative clinical and demographic characteristics, operative indications, and aneurysm extent. The 30-day outcomes, including mortality, major adverse cardiovascular events, and pulmonary and renal complications, were compared between the propensity-matched OSR and FEVAR groups. RESULTS A 1:1 propensity match was achieved, and the final analysis included 136 OSR patients and 136 FEVAR patients. No significant differences were found in 30-day mortality (4.4% vs 3.7%; odds ratio [OR], 1.21; 95% confidence interval [CI], 0.36-4.06; P = .759) between the OSR and FEVAR groups. OSR was associated with a higher incidence of major adverse cardiovascular events compared with FEVAR; however, the trend was not statistically significant (8.1% vs 3.7%; OR, 2.31; 95% CI, 0.78-6.82; P = .131). Compared with FEVAR, the OSR group had significantly greater rates of pulmonary complications (19.1% vs 3.7%; OR, 6.19; 95% CI, 2.30-16.67; P < .001) and renal complications (8.1% vs 2.2%; OR, 3.90; 95% CI, 1.06-14.31; P = .040). CONCLUSIONS In the samples assessed in the present study, the results with OSR of JAAAs in the elderly did not differ from those of FEVAR with respect to 30-day mortality despite a greater incidence of pulmonary and renal complications. Although FEVAR should remain the first-line therapy for JAAAs in elderly patients, OSR might be an acceptable alternative for select patients with anatomy unfavorable for FEVAR.
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Affiliation(s)
- Ethan S Rosenfeld
- Department of Surgery, The George Washington University, Washington, D.C..
| | - Robyn A Macsata
- Department of Surgery, The George Washington University, Washington, D.C
| | - Salim Lala
- Department of Surgery, The George Washington University, Washington, D.C
| | - K Benjamin Lee
- Department of Surgery, The George Washington University, Washington, D.C
| | - Benjamin J Pomy
- Department of Surgery, The George Washington University, Washington, D.C
| | - John J Ricotta
- Department of Surgery, The George Washington University, Washington, D.C
| | - Andrew D Sparks
- Department of Surgery, The George Washington University, Washington, D.C
| | - Richard L Amdur
- Department of Surgery, The George Washington University, Washington, D.C
| | - Anton N Sidawy
- Department of Surgery, The George Washington University, Washington, D.C
| | - Bao-Ngoc Nguyen
- Department of Surgery, The George Washington University, Washington, D.C
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15
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Oderich GS, Farber MA, Schneider D, Makaroun M, Sanchez LA, Schanzer A, Beck AW, Starnes BW, Fillinger M, Tenorio ER, Chen M, Zhou Q. Final 5-year results of the United States Zenith Fenestrated prospective multicenter study for juxtarenal abdominal aortic aneurysms. J Vasc Surg 2020; 73:1128-1138.e2. [PMID: 32891806 DOI: 10.1016/j.jvs.2020.08.128] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 08/14/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To report 5-year results of the prospective, multicenter study designed to evaluate the Zenith Fenestrated AAA Endovascular Graft (William A. Cook Australia, Brisbane, Australia) for juxtarenal abdominal aortic aneurysms (AAAs). METHODS Sixty-seven patients (54 male, mean age 74 ± 8 years) were prospectively enrolled at 14 U.S. centers from 2005 to 2012. Fenestrated stent grafts were used in patients with infrarenal aortic neck lengths of 4 to 14 mm to target 178 renal-mesenteric arteries with a mean of 2.7 vessels per patient. At 5 years, 42 of the 67 patients completed the final study follow-up, with clinical examination obtained in 41 and computed tomography imaging in 39. Outcomes adjudicated by a clinical events committee included all-cause and aneurysm-related mortality, major adverse events, renal stent occlusion/stenosis, renal function changes and renal infarcts, aneurysm sac enlargement (>5 mm), device migration (≥10 mm), type I/III endoleak, and secondary interventions. RESULTS Median follow-up was 59.8 months (range, 0.1-67.5 months). There were seven deaths, including one (1.5%) within 30 days (procedure-related) and six beyond 30 days (not procedure-related in five, indeterminate in one). At 5 years, freedom from all-cause mortality was 88.8 ± 4.2% and freedom from aneurysm-related mortality was 96.8 ± 2.3%. There were no aneurysm ruptures or conversions to open surgery. Of the 129 renal arteries targeted by fenestrations, five (4%) occluded and 14 (11%) developed in-stent stenosis. Treatment included redo stenting/angioplasty in 13 vessels, renal artery bypass in 2 vessels, and failed thrombectomy in 1 vessel. Primary and secondary renal target patency was 82.7 ± 4.1% and 95.7 ± 2.1% at 5 years, respectively. Dialysis was required in one patient who had pre-existing chronic kidney disease. During the 5 years, there was 1 type IA endoleak (1.5%), 1 type IB endoleak (1.5%), 2 device migrations (3%), and 4 aneurysm sac enlargements (6%). Overall, 81% of patients had sac shrinkage at 5 years. Of 20 patients who underwent secondary interventions, 12 were for renal in-stent stenosis or occlusion, 7 were for endoleak, and 1 was for both indications. Freedom from secondary intervention was 63.5 ± 7.2% at 5 years. CONCLUSIONS These 5-year results confirm the safety and effectiveness of the Zenith Fenestrated AAA stent graft with no late graft- or aneurysm-related deaths. In-stent stenosis of bare metal renal stents was the most frequent indication for secondary intervention. The low rate of type IA endoleak, sac enlargement, and device migration support its use in patients with juxtarenal AAAs.
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Affiliation(s)
- Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex.
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Darren Schneider
- Division of Vascular and Endovascular Surgery, Department of Surgery, Cornell-Weil Medical Center, New York, NY
| | - Michel Makaroun
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Luis A Sanchez
- Center for Advanced Medicine Heart & Vascular Center, Washington University, St Louis, Mo
| | - Andres Schanzer
- Division of Vascular Surgery, Department of Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Adam W Beck
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - Benjamin W Starnes
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Mark Fillinger
- Division of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Emanuel R Tenorio
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex
| | - Min Chen
- Cook Research Incorporated, West Lafayette, Ind
| | - Qing Zhou
- Cook Research Incorporated, West Lafayette, Ind
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16
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D'Oria M, Wanhainen A, DeMartino RR, Oderich GS, Lepidi S, Mani K. A scoping review of the rationale and evidence for cost-effectiveness analysis of fenestrated-branched endovascular repair for intact complex aortic aneurysms. J Vasc Surg 2020; 72:1772-1782. [PMID: 32473347 DOI: 10.1016/j.jvs.2020.05.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 05/05/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Cost-effectiveness analysis of new interventions is increasingly required by policymakers. For intact complex aortic aneurysms (CAAs), fenestrated-branched endovascular aneurysm repair (F/B-EVAR) offers a minimally invasive alternative option for patients who are physically ineligible for open surgical repair (OSR). Thus, F/B-EVAR is increasingly used, but whether it represents a cost-effective treatment option remains unknown. METHODS A scoping review of the literature was conducted from the PubMed, Ovid Embase, and Scopus databases. They were searched to identify relevant English-language articles published from inception to December 31, 2019. All costs in the identified literature were transformed to U.S. dollar values by the following exchange rate: 1 GBP = 1.3 USD; 1 EUR = 1.1 USD. RESULTS At this literature search, no randomized clinical trials assessing cost-effectiveness of F/B-EVAR vs OSR for intact CAAs were found. Also, no health economic evaluation studies were found regarding use of F/B-EVAR in patients unfit for OSR. A Markov model analysis based on seven observational center- or registry-based studies published from 2006 to 2014 found that the incremental cost-effectiveness ratio for F/B-EVAR vs OSR was $96,954/quality-adjusted life-year. In the multicenter French Medical and Economical Evaluation of Fenestrated and Branched Stent-grafts to Treat Complex Aortic Aneurysms (WINDOW) registry (2010-2012), F/B-EVAR had a higher cost than OSR for a similar clinical outcome and was therefore economically dominated. At 2 years, costs were higher with F/B-EVAR for juxtarenal/pararenal aneurysms and infradiaphragmatic thoracoabdominal aneurysms but similar for supradiaphragmatic thoracoabdominal aneurysms. The higher costs were related to a $24,278 cost difference of the initial admission (95% of the difference at 2 years) due to stent graft costs. Both these studies, however, included a highly varying center experience with complex endovascular aortic repair, and their retrospective design is subject to selection bias for chosen treatment, which could affect the studied outcome. In contrast, in a more recent U.S. database analysis (879 thoracoabdominal aortic aneurysm repairs, 45% OSRs), the unadjusted total hospitalization cost of OSR was significantly higher compared with F/B-EVAR (median, $44,355 vs $36,612; P = .004). In-hospital mortality as well as major complications were two to three times higher after OSR, indicating that endovascular repair might be the economically dominant strategy. CONCLUSIONS The literature regarding cost-effectiveness analysis of F/B-EVAR for intact CAAs is scarce and ambiguous. Based on the limited nonrandomized available evidence, stent grafts are the main driver for F/B-EVAR expenses, whereas cost-effectiveness in relation to OSR may vary by health care setting and selection of patients.
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Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden; Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUIGI, Trieste, Italy; Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, Minn
| | - Anders Wanhainen
- Division of Vascular and Endovascular Surgery, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Randall R DeMartino
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, Minn
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, Minn
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUIGI, Trieste, Italy
| | - Kevin Mani
- Division of Vascular and Endovascular Surgery, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.
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Davis FM, Albright J, Battaglia M, Eliason J, Coleman D, Mouawad N, Knepper J, Mansour MA, Corriere M, Osborne NH, Henke PK. Fenestrated repair improves perioperative outcomes but lacks a hospital volume association for complex abdominal aortic aneurysms. J Vasc Surg 2020; 73:417-425.e1. [PMID: 32473343 DOI: 10.1016/j.jvs.2020.05.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/15/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Complex abdominal aortic aneurysms (AAAs) have traditionally been treated with an open surgical repair (OSR). During the past decade, fenestrated endovascular aneurysm repair (FEVAR) has emerged as a viable option. Hospital procedural volume to outcome relationship for OSR of complex AAAs has been well established, but the impact of procedural volume on FEVAR outcomes remains undefined. This study investigated the outcomes of OSR and FEVAR for the treatment of complex AAAs and examined the hospital volume-outcome relationship for these procedures. METHODS A retrospective review of a statewide vascular surgery registry was queried for all patients between 2012 and 2018 who underwent elective repair of a juxtarenal/pararenal AAA with FEVAR or OSR. The primary outcomes were 30-day mortality, myocardial infarction, and new dialysis. Secondary end points included postoperative pneumonia, renal dysfunction (creatine concentration increase of >2 mg/dL from preoperative baseline), major bleeding, early procedural complications, length of stay, and need for reintervention. To evaluate procedural volume-outcomes relationship, hospitals were stratified into low- and high-volume aortic centers based on a FEVAR annual procedural volume. To account for baseline differences, we calculated propensity scores and employed inverse probability of treatment weighting in comparing outcomes between treatment groups. RESULTS A total of 589 patients underwent FEVAR (n = 186) or OSR (n = 403) for a complex AAA. After adjustment, OSR was associated with higher rates of 30-day mortality (10.7% vs 2.9%; P < .001) and need for dialysis (11.3% vs 1.8; P < .001). Postoperative pneumonia (6.8% vs 0.3%; P < .001) and need for transfusion (39.4% vs 10.4%; P < .001) were also significantly higher in the OSR cohort. The median length of stay for OSR and FEVAR was 9 days and 3 days, respectively. For those who underwent FEVAR, endoleaks were present in 12.1% of patients at 30 days and 6.1% of patients at 1 year, with the majority being type II. With a median follow-up period of 331 days (229-378 days), 1% of FEVAR patients required a secondary procedure, and there were no FEVAR conversions to an open aortic repair. Hospitals were divided into low- and high-volume aortic centers based on their annual FEVAR volume of complex AAAs. After adjustment, hospital FEVAR procedural volume was not associated with 30-day mortality or myocardial infarction. CONCLUSIONS FEVAR was associated with lower perioperative morbidity and mortality compared with OSR for the management of complex AAAs. Procedural FEVAR volume outcome analysis suggests limited differences in 30-day morbidity, although long-term durability warrants further research.
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Affiliation(s)
- Frank M Davis
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Jeremy Albright
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Mich
| | - Michael Battaglia
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Mich
| | - Jonathan Eliason
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Dawn Coleman
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | | | - Jordan Knepper
- Department of Surgery, Henry Ford Health System, Jackson, Mich
| | - M Ashraf Mansour
- Department of Surgery, Spectrum Health System, Grand Rapids, Mich
| | - Matthew Corriere
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Nicholas H Osborne
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
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Steffen M, Schmitz-Rixen T, Böckler D, Grundmann RT. Comparison of open and endovascular repair of juxtarenal abdominal aortic aneurysms. Langenbecks Arch Surg 2020; 405:207-213. [PMID: 32266530 DOI: 10.1007/s00423-020-01865-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 03/16/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND This study compares the perioperative outcome in elective repair of the juxtarenal abdominal aortic aneurysm (AAA), depending upon whether patients received an open (OAR) or endovascular procedure (EVAR). METHODS The database stems from the 2013-2017 AAA registry of the German Institute for Vascular Health Research (DIGG) of the German Society for Vascular Surgery and Vascular Medicine (DGG), with a total of 1603 juxtarenal AAAs. 786 patients (49.0%) were treated with an endovascular (EVAR) procedure, and 817 (51.0%) with an open (OAR) procedure. RESULTS Patients receiving EVAR had a median age of 73 years and those receiving OAR a median age of 71 years (p < 0.001). The proportion of patients over 80 years of age was 17.0% for EVAR and 9.9% for OAR (p < 0.001). The proportion of women receiving EVAR (16.9%) was slightly lower than that receiving OAR (18.6%). Aneurysm diameter differed significantly (EVAR mean 57.80 mm, OAR 59.07 mm; p = 0.038). Preoperatively impaired renal function stages 3 to 5 were not significantly different (EVAR 12.5%, OAR 14.4%, p = 0.158). Postoperative complications were significantly less with EVAR (31%) than with OAR at 45.7% (p = 0.001). In regard to MACE (major adverse cardiac events = perioperative death, stroke, or myocardial infarction), there were no significant differences between EVAR (8.8%) and OAR (10.3%) (p = 0.191). Hospital mortality was only in trend lower with EVAR than with OAR (5.7% vs. 7.7%, respectively; p = 0.068). This held true for the hospital mortality in the group above 80 years of age as well. Inpatient stay was 9 (13.3) days for EVAR and 14 (18.8) days for OAR (p < 0.001). The hospital mortality for women receiving EVAR was 10.5%, and significantly higher (p = 0.008) than that for men (4.7%). The same held true for OAR (hospital mortality for women was 11.8%, for men 6.8%; p = 0.030). CONCLUSION In terms of perioperative outcome, the endovascular procedure for treating juxtarenal AAA is more favorable than that documented for OAR. Further investigation is necessary to determine whether EVAR is comparable with OAR in the long term when treating juxtarenal AAA.
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Affiliation(s)
- M Steffen
- Klinikum Saarbrücken gGmbH, Winterberg 1, 66119, Saarbrücken, Germany
| | - Thomas Schmitz-Rixen
- Department of Vascular and Endovascular Surgery and the University Wound Center, University Hospital, Frankfurt am Main, Germany
| | - D Böckler
- Department of Vascular and Endovascular Surgery, University Hospital, Heidelberg, Germany
| | - Reinhart T Grundmann
- German Institute for Vascular Health Research (DIGG) of the German Society of Vascular Surgery and Vascular Medicine, Berlin, Germany.
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Pini R, Faggioli G, Gallitto E, Mascoli C, Fenelli C, Vacirca A, Gargiulo M. Predictors of Survival in Patients Over 80 Years Old Treated with Fenestrated and Branched Endograft. Ann Vasc Surg 2020; 67:52-58. [PMID: 32234393 DOI: 10.1016/j.avsg.2020.03.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/11/2020] [Accepted: 03/13/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Fenestrated and branched endovascular aneurysm repair endograft (f/bEVAR) allows the endovascular repair of thoracoabdominal and juxtarenal and pararenal abdominal aortic aneurysms (T-J-P-AAAs); however, given their high cost and complexity, their use should be limited to patients with life expectancy >2 years. Nevertheless, the number of patients older than 80 years treated by f/bEVAR is growing, with no hard evidence of the real efficacy in this context. The aim of the present study is to analyze the survival of ≥80-year-old patients treated with f/bEVAR, and to identify possible predictors of late mortality. METHODS An analysis of clinical, anatomical, and technical characteristics of patients treated with f/bEVAR for J-, P-, and T-AAA from 2010 to 2019 in a single academic center was performed. Follow-up data were collected prospectively with clinical visit and computed tomography angiography at discharge, after 6 months, and yearly thereafter. Survival after 2 years was evaluated by Kaplan-Meier analysis. Possible predictors of mortality were evaluated by univariable/multivariable analysis. RESULTS In the study period, a total of 243 f/bEVARs were considered: 83 for TAAA (34%) and 160 for J/PAAA (66%). Mean age was 73 ± 6 years, with 35 (14%) patients ≥80 years old; 209 patients (86%) were male and 78 (39%) had an American Society of Anesthesiology score IV. The 30-day and 2-year survival were 96% and 80 ± 3%, respectively. At a mean follow-up of 36 ± 25 months, independent predictors of late mortality by Cox regression analysis were chronic obstructive pulmonary disease (COPD), chronic renal failure (CRF), and ≥80 years old (hazard ratio [HR] 1.8, 95% confidence interval [CI] 1.02-3.2, P = 0.05; HR 1.7, 95% CI 1.01-3.4, P = 0.04; HR 3.1, 95% CI 1.5-6.3, P = 0.002, respectively). Preoperative clinical characteristics were similar in ≥80 years old versus younger patients, except for the prevalence of TAAA (14% vs. 38%, P = 0.04). The technical success and 30-day mortality were similar in ≥80 vs. <80-year-old patients (93% vs. 96%, P = 0.31; 7% vs. 3.5%, P = 0.60, respectively). The 2-year survival estimation was significantly lower in ≥80 years old compared with younger patients (62 ± 10% vs. 82 ± 3%, P = 0.003). The association of COPD and CRF significantly affects the 2-year survival in ≥80-year-old patients (no patients survived at 2 years) and was significantly different compared with the survival in ≥80-year-old patients without these risk factors (70 ± 11%, P = 0.001). CONCLUSIONS The early mortality rate and the 2-year survival after f/bEVAR justify this type of treatment in patients ≥80 years old; however, the presence of comorbidities such as COPD and CRF significantly reduces mid-term survival in this group and should be taken into consideration in the indication to f/bEVAR.
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Affiliation(s)
- Rodolfo Pini
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy.
| | - Gianluca Faggioli
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Enrico Gallitto
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Chiara Mascoli
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Cecilia Fenelli
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Andrea Vacirca
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Mauro Gargiulo
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
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20
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de Niet A, Zeebregts CJ, Reijnen MMPJ. Outcomes after treatment of complex aortic abdominal aneurysms with the fenestrated Anaconda endograft. J Vasc Surg 2019; 72:25-35.e1. [PMID: 31831315 DOI: 10.1016/j.jvs.2019.08.283] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 08/22/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To date, information on the fenestrated Anaconda endograft is limited to case series with a small sample size. This study was performed to assess the technical and clinical outcome of this device in a large international case series. METHODS All worldwide centers having treated more than 15 complex abdominal aortic aneurysms (AAA) or type IV thoracoabdominal aortic aneurysm patients with the fenestrated Anaconda endograft were approached. Main outcome parameters were procedural technical success, postoperative and follow-up clinical outcome for endoleaks, target vessel patency, reintervention rate, and patient survival. RESULTS Three hundred thirty-five consecutive cases treated between June 2010 and May 2018 in 11 sites were included. Patients were treated for a short neck infrarenal (n = 98), juxtarenal (n = 191), suprarenal AAA (n = 27), or type IV thoracoabdominal aortic aneurysm (n = 19). Mean age was 73.6 ± 4.6 years (292 male). Endografts contained a total of 920 fenestrations, with a mean of 2.7 ± 0.8 fenestrations per case. Technical success was 88.4% (primary, 82.7%; assisted primary 5.7%). In 6.9% of cases, a procedural type IA endoleak was observed, spontaneously disappearing in 82.6% during early follow-up. The development of a type IA endoleak was associated with greater neck angulation (odds ratio [OR], 0.94; P = .01), three fenestrations (OR, 42.7; P = .01) and the presence of augmented proximal rings (OR, 0.17; P = .03). Median follow-up was 1.2 years (interquartile range, 0.4-2.6). The mean estimated glomerular filtration rate deteriorated from 67.6 ± 19.3 mL/min/1.73 m2 preoperatively to 59.3 ± 22.7 mL/min/1.73 m2 at latest follow-up (P = .00). The freedom from AAA growth were 97.9 ± 0.9% (n = 190) and 86.4 ± 3.0% (n = 68), with a freedom from AAA rupture of 99.7 ± 0.3% (n = 191) and 99.1 ± 0.7% (n = 68), at 1 and 3 years, respectively. The endoleak-free survival, excluding spontaneously resolved procedural endoleaks, at 1 and 3 years was 73.4 ± 2.6 (n = 143) and 65.6 ± 3.4% (n = 45), respectively. The target vessel patency at one and three years were 96.4 ± 0.7% (n = 493) and 92.7 ± 1.4% (n = 156), respectively. A total of 75 reinterventions were done in 64 cases (19.1%), of which 25 cases for an endoleak. The reintervention-free survival at 1 and 3 years were 83.6 ± 2.2% (n = 190) and 71.0 ± 3.7% (n = 68), respectively. No deaths during procedure, extending within 24 hours postoperatively, were observed. Within 30 days 14 patients (4.2%) died and during follow-up another 39 patients (11.6%) died. Three deaths were considered AAA related (one rupture, one endograft infection, and one bilateral renal artery occlusion). The estimated cumulative survival at 1 and 3 years were 89.8 ± 1.8% (n = 191) and 79.2 ± 3.0% (n = 68), respectively. CONCLUSIONS The custom-made fenestrated Anaconda endograft is a valuable option for the treatment of a complex AAA. A procedural type IA endoleak is seen relatively frequently, but spontaneously resolves in most cases.
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Affiliation(s)
- Arne de Niet
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Michel M P J Reijnen
- Department of Surgery, Rijnstate, Arnhem, The Netherlands; Multimodality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, The Netherlands.
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Lareyre F, Raffort J, Carboni J, Chikande J, Massiot N, Voury-Pons A, Umbdenstock E, Hassen-Khodja R, Jean-Baptiste E. Impact of Polar Renal Artery Coverage after Fenestrated Endovascular Aortic Repair for Juxtarenal and Type IV Thoracoabdominal Aortic Aneurysms. Ann Vasc Surg 2019; 58:45-53.e1. [DOI: 10.1016/j.avsg.2018.10.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 10/26/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
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Varkevisser RR, O'Donnell TF, Swerdlow NJ, Liang P, Li C, Ultee KH, Pothof AB, De Guerre LE, Verhagen HJ, Schermerhorn ML. Fenestrated endovascular aneurysm repair is associated with lower perioperative morbidity and mortality compared with open repair for complex abdominal aortic aneurysms. J Vasc Surg 2019; 69:1670-1678. [DOI: 10.1016/j.jvs.2018.08.192] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 08/31/2018] [Indexed: 10/27/2022]
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Locham S, Dakour-Aridi H, Bhela J, Nejim B, Bhavana Challa A, Malas M. Thirty-Day Outcomes of Fenestrated and Chimney Endovascular Repair and Open Repair of Juxtarenal, Pararenal, and Suprarenal Abdominal Aortic Aneurysms Using National Surgical Quality Initiative Program Database (2012-2016). Vasc Endovascular Surg 2018; 53:189-198. [DOI: 10.1177/1538574418819284] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background: Fenestrated endovascular repair (FEVAR) and chimney endovascular repair (ChEVAR) endovascular repair offer a less invasive alternative to open aortic repair (OAR) in managing juxtarenal, pararenal, and suprarenal abdominal aortic aneurysms (AAAs). The aim of this study is to evaluate the 30-day postoperative outcomes following endovascular and open repair of nonruptured AAA involving the renal vessels. Study Design: All patients undergoing endovascular (FEVAR and ChEVAR) and open repair of juxtarenal, pararenal, and suprarenal AAA in National Surgical Quality Improvement Program database from 2012 to 2016 were included. Continuous and categorical covariates were analyzed using medians and χ2/Fisher exact test, respectively. Multivariable logistic regression analyses were performed to evaluate primary (mortality) and secondary (renal and cardiopulmonary failure) outcomes between open versus endovascular approach. Results: A total of 1191 patients underwent AAA repair using open (72%) or endovascular (FEVAR: 14%, ChEVAR: 14%) approach. In univariate analysis, no significant difference in 30-day mortality was seen between the 3 groups (FEVAR: 2.47% vs ChEVAR: 7.32% vs OAR: 6.13%, P = .13). However, 30-day major complications including renal failure (9.36% vs 6.10% vs 1.85%, P = .003) and cardiopulmonary complications (19.77% vs 3.66% vs 4.94%, P < 001) failure were significantly higher in patients undergoing OAR versus ChEVAR versus FEVAR. After adjusting for potential confounders, OAR was associated with 2- to 5-folds increased risk of mortality (odds ratio, OR [95% confidence interval, CI]: 2.14 [1.09-4.21], P = .03), renal (OR [95% CI]: 2.87 [1.48-5.57], P = .002), and cardiopulmonary failure (OR [95% CI]: 4.63 [2.47-8.67], P < .001) compared to any endovascular repair. Conclusion: Using a large national surgical data set, our study found 2- to 5-folds higher mortality and morbidity in patients undergoing open versus endovascular repair of AAA involving the renal vessels. Endovascular repair seems to be a safer approach, especially when managing older patients with AAA.
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Affiliation(s)
- Satinderjit Locham
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD, USA
- University of California San Diego, La Jolla, CA, USA
| | - Hanaa Dakour-Aridi
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD, USA
- University of California San Diego, La Jolla, CA, USA
| | - Jatminderpal Bhela
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD, USA
| | - Besma Nejim
- Penn State College of Medicine, Hershey, PA, USA
| | - Apurva Bhavana Challa
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD, USA
| | - Mahmoud Malas
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD, USA
- University of California San Diego, La Jolla, CA, USA
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Valentine EA, Zhou EY, Gordon EK, Ochroch EA. The Year in Vascular Anesthesia: Selected Highlights From 2017. J Cardiothorac Vasc Anesth 2018; 32:2043-2053. [PMID: 29784496 DOI: 10.1053/j.jvca.2018.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Elizabeth A Valentine
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Elizabeth Y Zhou
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Emily K Gordon
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - E Andrew Ochroch
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
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