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Ueda T, Fujitsuna R, Saito H, Yasui D, Sugihara F, Mine T, Shirai S, Matsumoto T, Kurita J, Ishii Y, Hayashi H, Kumita SI. Preemptive Embolization of Abdominal Aortic Aneurysm Sac Side Branch Arteries Promotes Early Sac Shrinkage after Endovascular Aneurysm Repair 1. Ann Vasc Surg 2024; 109:9-19. [PMID: 39025215 DOI: 10.1016/j.avsg.2024.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 06/02/2024] [Accepted: 06/06/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND The association between the occlusion rate of the side branch arteries branching from the abdominal aortic aneurysm sac and aneurysm sac shrinkage is unclear. We aimed to evaluate the efficacy of preemptive embolization of multiple side branch arteries branching from the abdominal aortic aneurysm sac in early aneurysm sac shrinkage after endovascular aneurysm repair. METHODS Patients undergoing endovascular aneurysm repair of abdominal aortic aneurysms, with or without preemptive embolization of multiple side branch arteries, including the inferior mesenteric artery and lumbar arteries, between January 2016 and August 2021, were retrospectively evaluated. Preemptive embolization was introduced at our institution in January 2018 and has been performed in all patients who undergo endovascular aneurysm repair since then. We compared occlusion rates of the side branch arteries, frequency of type 2 endoleaks, changes in aneurysm sac size, percentage of aneurysm sac size decrease, and frequency of reduction in the aneurysm sac diameter by > 5 mm. RESULTS The study included 43 patients in the embolization group and 20 in the nonembolization group. Preemptive embolization was successfully performed without any ischemic complications. The total occlusion rate of side branch arteries was significantly higher in the embolization group than in the nonembolization group (70.2% vs. 29.3%, P < 0.05). At 24 months of follow-up, the type 2 endoleak frequency was significantly lower in the embolization group than in the nonembolization group (6.9% vs. 31.6%, P < 0.05). The frequency of reduction in the aneurysm sac diameter by > 5 mm was significantly higher in the embolization group than in the nonembolization group at 24 months (62.1% vs. 31.6% P < 0.05). The optimal cutoff value for the total occlusion rate of the side branch arteries to achieve reduction in the aneurysm sac diameter by > 5 mm at 24 months, after endovascular aneurysm repair, was 66.7% in all patients (area under the curve = 0.634; sensitivity = 62.5%; specificity = 70.8%). These findings suggest that occluding 66.7% or more of the side branch arteries may result in early aneurysmal shrinkage. CONCLUSIONS Preemptive embolization of multiple side branch arteries, branching from the abdominal aortic aneurysm sac, may contribute to early aneurysm sac shrinkage; this may serve as a marker for fewer late complications after endovascular aneurysm repair.
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Affiliation(s)
- Tatsuo Ueda
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan.
| | - Ryutaro Fujitsuna
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Hidemasa Saito
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Daisuke Yasui
- Department of Radiology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Fumie Sugihara
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Takahiko Mine
- Department of Radiology, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Chiba, Japan
| | - Sayaka Shirai
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Taiga Matsumoto
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Jiro Kurita
- Department of Cardiovascular Surgery, Hanyu General Hospital, Hanyu, Saitama, Japan
| | - Yosuke Ishii
- Department of Cardiovascular Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Hiromitsu Hayashi
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
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Ding Y, Zhou M, Li X, Xie T, Zhou Z, Fang S, Shi Z, Fu W. The real-world incidence and predictors of sac regression in patients with infrarenal abdominal aortic aneurysm after standard EVAR. Asian J Surg 2024; 47:3026-3032. [PMID: 38403543 DOI: 10.1016/j.asjsur.2024.01.141] [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: 11/05/2023] [Revised: 01/21/2024] [Accepted: 01/26/2024] [Indexed: 02/27/2024] Open
Abstract
OBJECTIVE Sac regression (SR) is a surrogate marker of satisfied endovascular aneurysm repair (EVAR). This research aims to investigate the incidence and predictors of SR in a Chinese population. DESIGN Single centre retrospective cohort study. METHODS Consecutive patients with infrarenal abdominal aortic aneurysms (AAAs) who underwent standard EVAR were retrospectively reviewed. SR was defined as sac shrinkage > 5 mm on computed tomography images, while major SR (MaSR) was ≥ 10 mm sac shrinkage. The cumulative rate was calculated by Kaplan-Meier analysis and predictors were identified by the Cox regression model. RESULTS A total of 469 patients (median age, 71 years old) were included. The majority of them (86.6 %) were male. With a median time of 13.6 months, SR was detected in 129 (27.5 %) patients after the index EVAR. Compared with never smokers, current smokers were more likely to experience SR (adjusted HR 2.630, p < .001), while former smokers did not show any significant difference. Multivariate Cox regression also showed that maximal aneurysm diameter (adjusted HR 1.012, p = 0.035) and female (adjusted HR 1.675, p = .045) were independent predictors of SR. A total of 51 (10.9 %) patients had MaSR at a median time of 15.4 months after EVAR. In multivariate analysis, maximal aneurysm diameter and Zenith stent graft were independently associated with MaSR. CONCLUSION In Chinese population, the incidence of SR and MaSR was 27.5 % and 10.9 % after EVAR, respectively. Maximal aneurysm diameter and female were independent predictors of SR. Compared with never smokers, it was more likely to have SR in current smokers.
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Affiliation(s)
- Yong Ding
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
| | - Min Zhou
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
| | - Xu Li
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
| | - Tianchen Xie
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
| | - Zhenyu Zhou
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
| | - Sheng Fang
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
| | - Zhenyu Shi
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Institute of Vascular Surgery, National Clinical Research Center for Interventional Medicine, Fudan University, Shanghai, China.
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Smorenburg SPM, de Bruin JL, Zeebregts CJ, Reijnen MMPJ, Verhagen HJM, Heyligers JMM. Long Term Outcomes of the Gore Excluder Low Permeability Endoprosthesis for the Treatment of Infrarenal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2024; 68:18-27. [PMID: 38527519 DOI: 10.1016/j.ejvs.2024.03.028] [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: 09/07/2023] [Revised: 02/23/2024] [Accepted: 03/21/2024] [Indexed: 03/27/2024]
Abstract
OBJECTIVE This study evaluated the long term outcomes of endovascular aneurysm repair using the Gore Excluder Low Permeability (LP) endoprosthesis across high volume Dutch hospitals. METHODS A retrospective analysis was conducted of patients treated with the Excluder LP for infrarenal abdominal aortic aneurysm (AAA) in four hospitals between 2004 and 2017. Primary outcomes were overall survival, freedom from re-interventions (overall, inside and outside instructions for use, IFU), and AAA sac dynamics: growth (> 5 mm), stabilisation, and regression (< 5 mm). Secondary outcomes were technical success (device deployment), procedural parameters, and re-interventions. Follow up visits were extracted from patient files, with imaging assessed for complications and AAA diameter. RESULTS Five hundred and fourteen patients were enrolled, with a median (IQR) follow up of 5.0 (2.9, 6.9) years. Survival rates were 94.0% at one year, 73.0% at five years, and 37.0% at 10 years, with freedom from re-interventions of 89.0%, 79.0%, and 71.0%, respectively. 37.9% were treated outside IFU, leading to significantly more re-interventions over 10 years compared with those treated inside IFU (36.0% vs. 25.0%, respectively; p = .044). The aneurysm sac regressed by 53.5% at one year, 65.8% at five years, and 77.8% at 10 years, and grew by 9.8%, 14.3%, and 22.2%, respectively. Patients with one year sac growth had significantly worse survival (p = .047). Seven patients (1.4%) had a ruptured aneurysm during follow up. Over 15 years, type 1a endoleak occurred in 5.3%, type 1b in 3.1%, type 3 in 1.9%, type 4 in 0.2%, and type 2 in 35.6% of patients. CONCLUSION This multicentre study of real world endovascular aneurysm repair data using the Gore Excluder LP endoprosthesis demonstrated robust long term survival and re-intervention rates, despite 37.9% of patients being treated outside IFU, with type 4 endoleak being rare. Treatment outside IFU significantly increased re-intervention rates and one year sac growth was associated with statistically significantly worse survival.
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Affiliation(s)
- Stefan P M Smorenburg
- Department of Surgery, Amsterdam University Medical Centres location Vrije Universiteit, Amsterdam, the Netherlands
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Michel M P J Reijnen
- Department of Surgery, Rijnstate, Arnhem, the Netherlands; Multi-Modality Medical Imaging Group, University of Twente, Enschede, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Jan M M Heyligers
- Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands.
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Mehta A, Rastogi V, Yadavalli SD, Canta O, Giles K, Scali S, O'Donnell TFX, Patel VI, Schermerhorn ML. Long-term costs to Medicare associated with endovascular and open repairs of infrarenal and complex abdominal aortic aneurysms. J Vasc Surg 2024; 80:98-106. [PMID: 38490605 DOI: 10.1016/j.jvs.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVE The vast majority of patients with abdominal aortic aneurysms (AAAs) undergoing repairs receive endovascular interventions (EVARs) instead of open operations (OARs). Although EVARs have better short-term outcomes, OARs have improved longer-term durability and require less radiographic follow-up and monitoring, which may have significant implications on health care economics surrounding provision of AAA care nationally. Herein, we compared costs associated with EVAR and OAR of both infrarenal and complex AAAs. METHODS We examined patients undergoing index elective EVARs or OARs of infrarenal and complex AAAs in the 2014-2019 Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Network (VQI-VISION) dataset. We defined overall costs as the aggregated longitudinal costs associated with: (1) the index surgery; (2) reinterventions; and (3) imaging tests. We evaluated overall costs up to 5 years after infrarenal AAA repair and 3 years for complex AAA repair. Multivariable regressions adjusted for case-mix when evaluating cost differences between EVARs vs OARs. RESULTS We identified 23,746 infrarenal AAA repairs (8.7% OAR, 91% EVAR) and 2279 complex AAA repairs (69% OAR, 31% EVAR). In both cohorts, patients undergoing EVARs were more likely to be older and have more comorbidities. The cost for the index procedure for EVARs relative to OARs was lower for infrarenal AAAs ($32,440 vs $37,488; P < .01) but higher among complex AAAs ($48,870 vs $44,530; P < .01). EVARs had higher annual imaging and reintervention costs during each of the 5 postoperative years for infrarenal aneurysms and the 3 postoperative years for complex aneurysms. Among patients undergoing infrarenal AAA repairs who survived 5 years, the total 5-year cost of EVARs was similar to that of OARs ($35,858 vs $34,212; -$223 [95% confidence interval (CI), -$3042 to $2596]). For complex AAA repairs, the total cost at 3 years of EVARs was greater than OARs ($64,492 vs $42,212; +$9860 [95% CI, $5835-$13,885]). For patients receiving EVARs for complex aneurysms, physician-modified endovascular grafts had higher index procedure costs ($55,835 vs $47,064; P < .01) although similar total costs on adjusted analyses (+$1856 [95% CI, -$7997 to $11,710]; P = .70) relative to Zenith fenestrated endovascular grafts among those that were alive at 3 years. CONCLUSIONS Longer-term costs associated with EVARs are lower for infrarenal AAAs but higher for complex AAAs relative to OARs, driven by reintervention and imaging costs. Further analyses to characterize the financial viability of EVARs for both infrarenal and complex AAAs should evaluate hospital margins and anticipated changes in costs of devices.
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Affiliation(s)
- Ambar Mehta
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Aortic Center, New York-Presbyterian Columbia University Irving Medical Center, New York, NY; Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Sai Divya Yadavalli
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Olga Canta
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Kristina Giles
- Department of Vascular Surgery and Endovascular Therapy, Main Medical Center, Portland, ME
| | - Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Thomas F X O'Donnell
- Aortic Center, New York-Presbyterian Columbia University Irving Medical Center, New York, NY
| | - Virendra I Patel
- Aortic Center, New York-Presbyterian Columbia University Irving Medical Center, New York, NY
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Wang C, Zhang W, Wang G, Zou Z, Xu W, Fan X. Emergency endovascular repair for endoleak with rupture after frozen elephant trunk for type A aortic dissection. J Vasc Surg 2024; 80:268. [PMID: 37944772 DOI: 10.1016/j.jvs.2023.10.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Chaojie Wang
- Department of Cardiovascular Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wenqian Zhang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ge Wang
- Department of Cardiovascular Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zengxiao Zou
- Department of Cardiovascular Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wenliu Xu
- Department of Cardiovascular Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaoping Fan
- Department of Cardiovascular Surgery, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
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Rivoire E, Tresson P, Pialoux V, Josset L, Delrieu L, Millon A, Long A. Impact of Isolated Type 2 Endoleak on Subsequent Cardiovascular Events and Mortality. Ann Vasc Surg 2024; 108:307-316. [PMID: 38942363 DOI: 10.1016/j.avsg.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 06/21/2024] [Accepted: 06/21/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Assess subsequent cardiovascular events and all-cause mortality in patients with intact abdominal aortic aneurysm (AAA) treated by endovascular aneurysm repair (EVAR) according to the existence of isolated endoleak type 2 (EL2) at 1 year after EVAR implantation. METHODS This retrospective, single-center study included patients treated with EVAR between 2010 and 2017 in the vascular surgery department of the University Hospital of Lyon with an infrarenal AAA > 50 mm. The baseline clinical characteristics collected just before EVAR were retrieved from electronic patient records of our institution. AAA characteristics, procedure, and the 1-year postoperative computed tomography angiography (CTA) were reported. Study end points, major adverse cardiovascular events (MACE), major adverse lower-extremity events (MALE), and all-cause mortality were recorded during follow-up. Patients were divided into 2 groups according to the presence of isolated EL2 (EL2 +) or absence (EL2 -) of any endoleak on CTA at 1 year. MACE, MALE, and all-cause mortality were compared between both groups. RESULTS During the study period, 589 patients were treated by endovascular surgery and 207 were included. According to the CTA results at 1 year, 60 patients (29%) were included in the EL2 + group and 147 patients (71%) in the EL2 - group. A total of 109 patients (53%) experienced a MACE or MALE; significantly fewer patients in the EL2 + than in the EL2 - group did so (P = 0.009). There were 47 patients (23%) who experienced at least 1 MALE, and the frequency was significantly lower in the EL2 + group (P = 0.017). CONCLUSIONS Patients with AAA treated by EVAR who did not develop EL2 at 1 year were at higher risk of MALE during follow-up. This might be explained by more frequent symptomatic lower extremity peripheral arterial disease at baseline in this group. These patients therefore require a closer follow-up and strict control of cardiovascular risk factors to prevent cardiovascular morbi-mortality.
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Affiliation(s)
- Emeraude Rivoire
- Service de Chirurgie Vasculaire et Endovasculaire, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France; Service de Médecine Interne et de Médecine Vasculaire, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France; Universite Claude Bernard Lyon 1, LIBM UR 7424, Team Atherosclerosis, Thrombosis and Physical Activity, Lyon, France.
| | - Philippe Tresson
- Service de Chirurgie Vasculaire et Endovasculaire, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Vincent Pialoux
- Universite Claude Bernard Lyon 1, LIBM UR 7424, Team Atherosclerosis, Thrombosis and Physical Activity, Lyon, France
| | - Laurie Josset
- Universite Claude Bernard Lyon 1, LIBM UR 7424, Team Atherosclerosis, Thrombosis and Physical Activity, Lyon, France
| | - Lidia Delrieu
- Universite Claude Bernard Lyon 1, LIBM UR 7424, Team Atherosclerosis, Thrombosis and Physical Activity, Lyon, France
| | - Antoine Millon
- Service de Chirurgie Vasculaire et Endovasculaire, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France; Universite Claude Bernard Lyon 1, LIBM UR 7424, Team Atherosclerosis, Thrombosis and Physical Activity, Lyon, France
| | - Anne Long
- Service de Chirurgie Vasculaire et Endovasculaire, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France; Service de Médecine Interne et de Médecine Vasculaire, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France; Universite Claude Bernard Lyon 1, LIBM UR 7424, Team Atherosclerosis, Thrombosis and Physical Activity, Lyon, France
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Figueroa AV, Tanenbaum MT, Timaran CH, Oderich GS, Eagleton MJ, Schanzer A, Farber MA, Beck AW, Schneider DB, Gasper W, Sweet MP, Lee A, Cantor RS, Li X. Postdissection aortic aneurysm sac enlargement after fenestrated and branched endovascular aortic aneurysm repair. J Vasc Surg 2024:S0741-5214(24)01092-9. [PMID: 38909915 DOI: 10.1016/j.jvs.2024.04.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 04/29/2024] [Accepted: 04/29/2024] [Indexed: 06/25/2024]
Abstract
OBJECTIVES Aneurysm sac changes after fenestrated-branched endovascular aneurysm repair (FBEVAR) for postdissection thoracoabdominal aortic aneurysms (PD-TAAs) are poorly understood. Partial thrombosis of the false lumen and endoleaks may impair sac regression. To characterize sac changes after FBEVAR for PD-TAAs, this study examined midterm results and predictors for sac enlargement. METHODS FBEVARs performed for PD-TAAs in 10 physician-sponsored investigational device exemption studies from 2008 to 2023 were analyzed. The maximum aortic aneurysm diameter was compared between the 30-day computed tomography angiogram and follow-up imaging studies. Aneurysm sac enlargement was defined as an increase in diameter of ≥5 mm. Kaplan-Meier curves and Cox regression were used to evaluate sac enlargement and midterm FBEVAR outcomes. RESULTS Among 3296 FBEVARs, 290 patients (72.4% male; median age, 68.4 years) were treated for PD-TAAs. Most aneurysms treated were extent II (72%) and III (12%). Mean aneurysm diameter was 66.5 ± 11.2 mm. Mortality at 30 days was 1.4%. At a mean follow-up of 2.9 ± 1.9 years, at least one follow-up imaging study revealed sac enlargement in 43 patients (15%), sac regression in 115 patients (40%), and neither enlargement nor regression in 137 (47%); 5 (2%) demonstrated both expansion and regression during follow-up. Freedom from aneurysm sac enlargement was 93%, 82%, and 80% at 1, 3, and 5 years, respectively. Overall, endoleaks were detected in 27 patients (63%) with sac enlargement and 143 patients (58%) without enlargement (P = .54). Sac enlargement was significantly more frequent among older patients (mean age at the index procedure, 70.2 ± 8.9 years vs 66.5 ± 11 years; P = .04) and those with type II endoleaks at 1 year (74% vs 52%; P = .031). Cox regression revealed age >70 years at baseline (hazard ratio [HR], 2.146; 95% confidence interval [CI], 1.167-3.944; P = .010) and presence of type II endoleak at 1 year (HR, 2.25; 95% CI, 1.07-4.79; P = .032) were independent predictors of sac enlargement. Patient survival was 92%, 81%, and 68% at 1, 3, and 5 years, respectively. Cumulative target vessel instability was 7%, and aneurysm-related mortality was 2% at 5 years. At least 42% of patients required secondary interventions. Sac enlargement did not affect patient survival. CONCLUSIONS Aneurysm sac enlargement occurs in 15% of patients after FBEVAR for PD-TAAs. Elderly patients (>70 years at baseline) and those with type II endoleaks at 1 year may need closer monitoring and secondary interventions to prevent sac enlargement. Despite sac enlargement in some patients, aneurysm-related mortality at 5 years remains low and overall survival was not associated with sac enlargement.
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Affiliation(s)
- Andres V Figueroa
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mira T Tanenbaum
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Gustavo S Oderich
- Division of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Memorial Hospital, Worcester, MA
| | - Mark A Farber
- Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
| | - Adam W Beck
- Division of Vascular and Endovascular Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Darren B Schneider
- Division of Vascular and Endovascular Surgery, University of Pennsylvania, Philadelphia, PA
| | - Warren Gasper
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA
| | - Matthew P Sweet
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Anthony Lee
- Division of Vascular Surgery, Boca Raton Regional Hospital, Boca Raton, FL
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Rašiová M, Koščo M, Pavlíková V, Hudák M, Moščovič M, Kočan L. Predictors of overall mortality after endovascular abdominal aortic repair - A single centre study. Vascular 2024:17085381241262350. [PMID: 38872254 DOI: 10.1177/17085381241262350] [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: 06/15/2024]
Abstract
OBJECTIVES A current and ongoing challenge is to reduce patient mortality after endovascular abdominal aortic repair (EVAR). This study aimed to assess the predictors of all-cause mortality after EVAR. METHODS Data regarding the demographic characteristics, comorbidities, laboratory values, selected anatomical factors, post-EVAR treatment, surveillance and complications of patients who underwent elective EVAR for non-ruptured abdominal aortic aneurysm (AAA) between January 2010 and January 2021 were evaluated. Mortality was assessed until 10 October 2023. Multivariate analyses were performed after adjusting for age, hypertension, diabetes mellitus, dyslipidaemia, sex, smoking, number of lumbar arteries, patency of inferior mesenteric artery (IMA), IMA diameter and reinterventions. RESULTS This study included 196 patients (183 men and 13 women) with a mean age of 72.4 ± 7.67 years. The overall mortality rate during a mean follow-up period of 5.75 ± 3.1 years was 50.0% (N = 98). The 2-, 5- and 10-year mortality rates were 9.7%, 32.0% and 66.6%, respectively. The mortality rates decreased by 59% in patients with reinterventions (hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.23-0.73; p = .002) and by 59% in patients treated with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) (HR: 0.41; 95% CI: 0.26-0.66; p < .001). Chronic anticoagulation was associated with 2.09-fold higher mortality (HR: 2.09; 95% CI: 1.19-3.67; p = .010), and coronary artery disease (CAD) was associated with 1.74-fold higher mortality (HR: 1.74; 95% CI: 1.09-2.78; p = .021). Pre-EVAR AAA diameter and 1-year post-EVAR sac diameter were positively associated with mortality (HR: 1.05; 95% CI: 1.03-1.08; p < .001, and HR: 1.05; 95% CI: 1.03-1.07; p < .001, respectively), that is, an increase of pre-EVAR and/or 1-year post-EVAR AAA diameter by 1 mm was associated with a 5% higher risk of all-cause mortality. CONCLUSIONS Reinterventions and treatment with ACE inhibitors or ARBs may be associated with decreased post-EVAR mortality. A greater pre-EVAR, a post-EVAR AAA diameter, CAD and chronic anticoagulation were associated with higher all-cause mortality post-EVAR.
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Affiliation(s)
- Mária Rašiová
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Martin Koščo
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Veronika Pavlíková
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Marek Hudák
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Matej Moščovič
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Ladislav Kočan
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
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Chao CL, Applewhite B, Reddy NK, Matiuto N, Dang C, Jiang B. Advances and challenges in regenerative therapies for abdominal aortic aneurysm. Front Cardiovasc Med 2024; 11:1369785. [PMID: 38895536 PMCID: PMC11183335 DOI: 10.3389/fcvm.2024.1369785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
Abdominal aortic aneurysm (AAA) is a significant source of mortality worldwide and carries a mortality of greater than 80% after rupture. Despite extensive efforts to develop pharmacological treatments, there is currently no effective agent to prevent aneurysm growth and rupture. Current treatment paradigms only rely on the identification and surveillance of small aneurysms, prior to ultimate open surgical or endovascular repair. Recently, regenerative therapies have emerged as promising avenues to address the degenerative changes observed in AAA. This review briefly outlines current clinical management principles, characteristics, and pharmaceutical targets of AAA. Subsequently, a thorough discussion of regenerative approaches is provided. These include cellular approaches (vascular smooth muscle cells, endothelial cells, and mesenchymal stem cells) as well as the delivery of therapeutic molecules, gene therapies, and regenerative biomaterials. Lastly, additional barriers and considerations for clinical translation are provided. In conclusion, regenerative approaches hold significant promise for in situ reversal of tissue damages in AAA, necessitating sustained research and innovation to achieve successful and translatable therapies in a new era in AAA management.
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Affiliation(s)
- Calvin L. Chao
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Brandon Applewhite
- Department of Biomedical Engineering, Northwestern University McCormick School of Engineering, Chicago, IL, United States
| | - Nidhi K. Reddy
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Natalia Matiuto
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Caitlyn Dang
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Bin Jiang
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Department of Biomedical Engineering, Northwestern University McCormick School of Engineering, Chicago, IL, United States
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10
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Gallitto E, Faggioli GL, Campana F, Feroldi FM, Cappiello A, Caputo S, Pini R, Gargiulo M. Type II endoleaks after fenestrated/branched endografting for juxtarenal and pararenal aortic aneurysms. J Vasc Surg 2024; 79:1295-1304.e2. [PMID: 38280685 DOI: 10.1016/j.jvs.2024.01.197] [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: 11/18/2023] [Revised: 12/28/2023] [Accepted: 01/01/2024] [Indexed: 01/29/2024]
Abstract
OBJECTIVE Persistent type II endoleaks (pEL2s) are not uncommon after endovascular aneurysm repair and their impact on long-term outcomes is well-documented. However, their occurrence and natural history after fenestrated/branched endografting (F/B-EVAR) for juxtarenal and pararenal aneurysms (J/P-AAAs) have been scarcely investigated. Aim of this study was to report incidence, risk factors, and natural history of pEL2 after F/B-EVAR in J/P-AAAs. METHODS Between 2016 and 2022, all J/P-AAAs undergoing F/B-EVAR were prospectively collected and retrospectively analyzed. EL2 were assessed at the completion angiography, at 30 days and after 6 months as primary outcomes. Preoperative risk factors for pEL2, follow-up survival, freedom from reinterventions (FFR) and aneurysm shrinkage (≥5 mm) were considered as secondary outcomes. RESULTS Of 132 patients, there were 88 (67%) JAAAs and 44 (33%) PAAAs. Seventeen EL2 (13%) were detected at the completion angiography and 36 (27%) at 30-day computed tomography angiography. The mean follow-up was 28 ± 23 months. Eleven (31%) EL2 sealed spontaneously within 6 months and three new cases were detected, for an overall of 28 pEL2/107 patients (26%) with available radiological follow-up of ≥6 months. Preoperative antiplatelet therapy (odds ratio, 4.7; 95% confidence interval [CI[, 1-22.1; P = .05), aneurysm thrombus volume of ≤40% and six or more patent aneurysm afferent vessels (odds ratio, 7.2; 95% CI, 1.8-29.1; P = .005) were independent risk factors for pEL2. The estimated 3-year survival was 80%, with no difference between cases with and without pEL2 (78% vs 85%; P = .08). The estimated 3-year FFR was 86%, with no difference between cases with and without pEL2 (81% vs 87%; P = .41). Four cases (3%) of EL2-related reinterventions were performed. In 65 cases (49%), aneurysm shrinkage was detected. pEL2 was an independent risk factor for absence of aneurysm shrinkage during follow-up (hazard ratio, 3.2; 95% CI, 1.2-8.3; P = .014). Patients without shrinkage had lower follow-up survival (64% vs 86% at 3-year; P = .009) and FFR (74% vs 90% at 3 years; P = .014) than patients with shrinkage. CONCLUSIONS PEL2 is not infrequent (26%) after F/B-EVAR for J/P-AAAs and is correlated with preoperative antiplatelet therapy, aneurysm thrombus volume of ≤40%, and six or more patent sac afferent vessels. Patients with pEL2 have a diminished aneurysm shrinkage, which is correlated with lower follow-up survival and FFR compared with patients with aneurysm shrinkage.
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Affiliation(s)
- Enrico Gallitto
- Vascular Surgery, University of Bologna, Bologna, Italy; Vascular Surgery, IRCCS, Sant'Orsola Malpighi, Bologna, Italy.
| | - Gian Luca Faggioli
- Vascular Surgery, University of Bologna, Bologna, Italy; Vascular Surgery, IRCCS, Sant'Orsola Malpighi, Bologna, Italy
| | | | | | | | | | - Rodolfo Pini
- Vascular Surgery, University of Bologna, Bologna, Italy; Vascular Surgery, IRCCS, Sant'Orsola Malpighi, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, University of Bologna, Bologna, Italy; Vascular Surgery, IRCCS, Sant'Orsola Malpighi, Bologna, Italy
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11
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Reyes Valdivia A, Oikonomou K, Milner R, Kasprzak P, Reijnen MMPJ, Pitoulias G, Torsello GB, Pfister K, de Vries JPPM, Chaudhuri A. The Effect of EndoAnchors on Aneurysm Sac Regression for Patients Treated With Infrarenal Endovascular Repair With Hostile Neck Anatomies: A Propensity Scored Analysis. J Endovasc Ther 2024; 31:438-449. [PMID: 36214450 DOI: 10.1177/15266028221127839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To analyze sac evolution patterns in matched patients with hostile neck anatomy (HNA) treated with standard endovascular aneurysm repair (sEVAR) and endosutured aneurysm repair (ESAR). METHODS Observational retrospective study using prospectively collected data between June 2010 and December 2019. ESAR group data were extracted from the primary arm of the PERU registry with an assigned identifier (NCT04100499) at 8 centers and those from the sEVAR came from 4 centers. Suitability for inclusion required: no proximal endograft adjuncts (besides EndoAnchor use), ≤15 mm neck length and minimum of 12-months follow-up imaging. Bubble-shaped neck (noncylindrical short neck with discontinuous seal) aspect was analyzed. Both groups were analyzed using propensity score matching (PSM) for aortic neck length, width, angulation, and device fixation type. Main outcome assessed was sac evolution patterns (sac expansion and regression were defined as >5mm increase or decrease, of the maximum sac diameter respectively; all AAAs within this ±5 mm range in diameter change were considered stable) and secondary outcomes were type-Ia endoleaks; other endoleaks and mortality. A power analysis calculation >80% was confirmed for sac regression evaluation. RESULTS After exclusions, PSM resulted in 96 ESAR and 96 sEVAR patients. Mean imaging follow-up (months) was 44.4±21.3 versus 43.0±19.6 (p=0.643), respectively. The overall number of patients achieving sac regression was higher in the ESAR group (n=57, 59.4% vs n=31, 32.3%; p<0.001) and the cumulative sac regression achieved at 5 years was 65% versus 38% (p=0.003) in favor of the ESAR group. There were no statistically significant differences in type-Ia endoleak and/or other endoleaks. Univariate analysis for sac regression patients in the sEVAR and ESAR group individually showed the bubble-shape neck as a predictor of sac regression failure. There were no statistical differences in overall and aneurysm-related mortality. CONCLUSION Endosutured aneurysm repair provided improved rates of sac regression for patients with AAA and HNA when compared with sEVAR at midterm and up to 5 years, despite similar rates of type-Ia endoleaks, and the need to consider some important limitations. The presence of bubble-shaped neck was a predictor of sac regression failure for both groups equally. CLINICAL IMPACT The use of EndoAnchors aids and improves EVAR treatment in hostile neck anatomies by an increased rate of sac regression when compared to EVAR treatment alone in up to 5 year analysis. Moreover, a trend to reduced number of type Ia endoleaks is also achieved, although not significant in the present study. This data, adds to current and growing evidence on the usefulness of EndoAnchors for AAA endovascular treatment.
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Affiliation(s)
- Andrés Reyes Valdivia
- Department of Vascular and Endovascular Surgery, Ramón y Cajal's University Hospital, Madrid, Spain
| | - Kyriakos Oikonomou
- Department of Vascular Surgery, University Medical Centre Regensburg, Regensburg, Germany
- Department of Vascular and Endovascular Surgery, Cardiovascular Surgery Clinic, University Hospital Frankfurt and Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Ross Milner
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Piotr Kasprzak
- Department of Vascular Surgery, University Medical Centre Regensburg, Regensburg, Germany
| | - Michel M P J Reijnen
- Department of Surgery, Rijnstate, Arnhem, The Netherlands
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Georgios Pitoulias
- Division of Vascular Surgery, 2nd Department of Surgery, Faculty of Medicine, "G. Gennimatas" Thessaloniki General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Karin Pfister
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Jean-Paul P M de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Arindam Chaudhuri
- Bedfordshire-Milton Keynes Vascular Center, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
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12
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Gilmore BF, Scali ST, D’Oria M, Neal D, Schermerhorn ML, Huber TS, Columbo JA, Stone DH. Temporal Trends and Outcomes of Abdominal Aortic Aneurysm Care in the United States. Circ Cardiovasc Qual Outcomes 2024; 17:e010374. [PMID: 38775052 PMCID: PMC11187661 DOI: 10.1161/circoutcomes.123.010374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 04/08/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) has had a dynamic impact on abdominal aortic aneurysm (AAA) care, often supplanting open AAA repair (OAR). Accordingly, US AAA management is often highlighted by disparities in patient selection and guideline compliance. The purpose of this analysis was to define secular trends in AAA care. METHODS The Society for Vascular Surgery Vascular Quality Initiative was queried for all EVARs and OARs (2011-2021). End points included procedure utilization, change in mortality, patient risk profile, Society for Vascular Surgery-endorsed diameter compliance, off-label EVAR use, cross-clamp location, blood loss, in-hospital complications, and post-EVAR surveillance missingness. Linear regression was used without risk adjustment for all end points except for mortality and complications, for which logistic regression with risk adjustment was used. RESULTS In all, 66 609 EVARs (elective, 85% [n=55 805] and nonelective, 15% [n=9976]) and 13 818 OARs (elective, 70% [n=9706] and nonelective, 30% [n=4081]) were analyzed. Elective EVAR:OAR ratios were increased (0.2 per year [95% CI, 0.01-0.32]), while nonelective ratios were unchanged. Elective diameter threshold noncompliance decreased for OAR (24%→17%; P=0.01) but not EVAR (mean, 37%). Low-risk patients increasingly underwent elective repairs (EVAR, +0.4%per year [95% CI, 0.2-0.6]; OAR, +0.6 points per year [95% CI, 0.2-1.0]). Off-label EVAR frequency was unchanged (mean, 39%) but intraoperative complications decreased (0.5% per year [95% CI, 0.2-0.9]). OAR complexity increased reflecting greater suprarenal cross-clamp rates (0.4% per year [95% CI, 0.1-0.8]) and blood loss (33 mL/y [95% CI, 19-47]). In-hospital complications decreased for elective (0.7% per year [95% CI, 0.4-0.9]) and nonelective EVAR (1.7% per year [95% CI, 1.1-2.3]) but not OAR (mean, 42%). A 30-day mortality was unchanged for both elective OAR (mean, 4%) and EVAR (mean, 1%). Among nonelective OARs, an increase in both 30-day (0.8% per year [95% CI, 0.1-1.5]) and 1-year mortality (0.8% per year [95% CI, 0.3-1.6]) was observed. Postoperative EVAR surveillance acquisition decreased (67%→49%), while 1-year mortality among patients without imaging was 4-fold greater (9.2% versus imaging, 2.0%; odds ratio, 4.1 [95% CI, 3.8-4.3]; P<0.0001). CONCLUSIONS There has been an increase in EVAR and a corresponding reduction in OAR across the United States, despite established concerns surrounding guideline adherence, reintervention, follow-up, and cost. Although EVAR morbidity has declined, OAR complication rates remain unchanged and unexpectedly high. Opportunities remain for improving AAA care delivery, patient and procedure selection, guideline compliance, and surveillance.
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Affiliation(s)
- Brian F. Gilmore
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Salvatore T. Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Mario D’Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas S. Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Jesse A. Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - David H. Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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13
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Simons JP. Is it time to shift our focus away from postoperative endoleaks to postoperative sac behavior? J Vasc Surg 2024; 79:1305. [PMID: 38777548 DOI: 10.1016/j.jvs.2024.01.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 01/20/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Jessica P Simons
- Division of Vascular and Endovascular Surgery, UMass Chan Medical School, Worcester, Massachusetts
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14
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Sulzer TAL, de Bruin JL, Rastogi V, Boer GJ, Mesnard T, Fioole B, Rijn MJV, Schermerhorn ML, Oderich GS, Verhagen HJM. Midterm Outcomes and Aneurysm Sac Dynamics Following Fenestrated Endovascular Aneurysm Repair after Previous Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2024; 67:886-893. [PMID: 38301871 DOI: 10.1016/j.ejvs.2024.01.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/19/2023] [Accepted: 01/23/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Fenestrated endovascular aneurysm repair (FEVAR) is a feasible option for aortic repair after endovascular aneurysm repair (EVAR), due to improved peri-operative outcomes compared with open conversion. However, little is known regarding the durability of FEVAR as a treatment for failed EVAR. Since aneurysm sac evolution is an important marker for success after aneurysm repair, the aim of the study was to examine midterm outcomes and aneurysm sac dynamics of FEVAR after prior EVAR. METHODS Patients undergoing FEVAR for complex abdominal aortic aneurysms from 2008 to 2021 at two hospitals in The Netherlands were included. Patients were categorised into primary FEVAR and FEVAR after EVAR. Outcomes included five year mortality rate, one year aneurysm sac dynamics (regression, stable, expansion), sac dynamics over time, and five year aortic related procedures. Analyses were done using Kaplan-Meier methods, multivariable Cox regression analysis, chi square tests, and linear mixed effect models. RESULTS One hundred and ninety-six patients with FEVAR were identified, of whom 27% (n = 53) had had a prior EVAR. Patients with prior EVAR were significantly older (78 ± 6.7 years vs. 73 ± 5.9 years, p < .001). There were no significant differences in mortality rate. FEVAR after EVAR was associated with a higher risk of aortic related procedures within five years (hazard ratio [HR] 2.6; 95% confidence interval [CI] 1.1 - 6.5, p = .037). Sac dynamics were assessed in 154 patients with available imaging. Patients with a prior EVAR showed lower rates of sac regression and higher rates of sac expansion at one year compared with primary FEVAR (sac expansion 48%, n = 21/44, vs. 8%, n = 9/110, p < .001). Sac dynamics over time showed similar results, sac growth for FEVAR after EVAR, and sac shrinkage for primary FEVAR (p < .001). CONCLUSION There were high rates of sac expansion and a need for more secondary procedures in FEVAR after EVAR than primary FEVAR patients, although this did not affect midterm survival. Future studies will have to assess whether FEVAR after EVAR is a valid intervention, and the underlying process that drives aneurysm sac growth following successful FEVAR after EVAR.
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Affiliation(s)
- Titia A L Sulzer
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA.
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gert Jan Boer
- Department of Vascular Surgery, Maasstad Hospital Rotterdam, The Netherlands
| | - Thomas Mesnard
- The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital Rotterdam, The Netherlands
| | - Marie Josee van Rijn
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Gustavo S Oderich
- The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
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15
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Nguyen T, Gittinger M, Gryzbowski C, Patel S, Asirwatham M, Grundy S, Zwiebel B, Shames M, Arnaoutakis DJ. One-hundred Consecutive Physician-Modified Fenestrated Endovascular Aneurysm Repair of Pararenal and Thoracoabdominal Aortic Aneurysms Using the Terumo TREO Stent Graft. Ann Vasc Surg 2024; 106:369-376. [PMID: 38823478 DOI: 10.1016/j.avsg.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Fenestrated endovascular aortic aneurysm repair (FEVAR) has been widely applied for the treatment of pararenal (PAA) and thoracoabdominal aortic aneurysms (TAAA). If custom-made devices or off-the-shelf devices are not available, physician-modified endografts (PMEGs) are an alternative device option. Several different endograft platforms have been used for PMEG; however, minimal data exists on utilizing the Terumo TREO abdominal stent graft system in this setting. The purpose of this study was to evaluate our single-center experience treating PAA and TAAA, with a physician-modified FEVAR, using the Terumo TREO platform. METHODS A prospective database of consecutive patients with PAA and TAAA treated at a single center, with a FEVAR, utilizing a PMEG device between March 2021 and September 2023 was queried for those having a Terumo TREO device implanted. The demographics, operative details, and postoperative complications were analyzed. The rates of technical success, type I or III endoleak, branch vessel status, reintervention, and 2-year survival were also assessed. RESULTS Of the 153 patients who underwent FEVAR with a PMEG device during the study period, 100 had repair using a Terumo TREO stent graft. The mean age of the cohort was 73.7 ± 7.0 years with the majority suffering from hypertension (n = 94, 94%), coronary artery disease (n = 51, 51%), and chronic obstructive pulmonary disease (n = 40, 40%). Thirty-four patients (34%) had a prior failed EVAR device in place. The mean aneurysm size was 66.0 ± 13.7 mm, with 58 (50%) patients classified as PAA and 30 (30%) patients as an extent IV TAAA. Six (6%) patients presented with symptomatic/ruptured aneurysms. The average number of target arteries incorporated per patient was 3.8 ± 0.6. The overall technical success was 99%, procedure time was 218 ± 116 min, contrast volume was 82 ± 21 mL, and cumulative air kerma was 3,054 ± 1,560 mGy. Postoperative complications were present in 20 patients (20%), and 2 patients (2%) died within 30 days. Rates of type I or III endoleak, branch vessel stenosis or occlusion, and reintervention were 2%, 1%, and 7%, respectively. The two-year overall survival was 87%. CONCLUSIONS Treatment of PAA and the extent IV TAAA using a physician-modified fenestrated Terumo TREO endograft is safe and effective. This large, early experience using the Terumo TREO platform supports preferential use of this device in this setting due to the device design and low likelihood of type I or III endoleak.
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Affiliation(s)
- Trung Nguyen
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Mackenzie Gittinger
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Cara Gryzbowski
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Shivam Patel
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Mark Asirwatham
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Shane Grundy
- Department of Radiology, Tampa General Hospital, Tampa, FL
| | - Bruce Zwiebel
- Department of Radiology, Tampa General Hospital, Tampa, FL
| | - Murray Shames
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Dean J Arnaoutakis
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL.
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Mesnard T, Sulzer TAL, Kanamori LR, Babocs D, Vacirca A, Baghbani-Oskouei A, Savadi S, Tenorio ER, Mirza A, Saqib N, Mendes B, Macedo T, Verhagen HJM, Huang Y, Oderich GS. Aneurysm sac shrinkage at 1 year after fenestrated-branched endovascular aortic repair of complex aortic aneurysms offers mid-term survival advantage. J Vasc Surg 2024:S0741-5214(24)01233-3. [PMID: 38825213 DOI: 10.1016/j.jvs.2024.05.054] [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: 02/29/2024] [Revised: 05/24/2024] [Accepted: 05/24/2024] [Indexed: 06/04/2024]
Abstract
OBJECTIVES To investigate the impact of 1-year changes in aneurysm sac diameter on patient survival after fenestrated-branched endovascular aortic repair (FB-EVAR) of complex abdominal aortic aneurysms or thoracoabdominal aortic aneurysms. METHODS We reviewed the clinical data of patients enrolled in a prospective nonrandomized study investigating FB-EVAR (2013-2022). Patients with sequential follow up computed tomography scans at baseline and 6 to 18 months after FB-EVAR were included in the analysis. Aneurysm sac diameter change was defined as the difference in maximum aortic diameter from baseline measurements obtained in centerline of flow. Patients were classified as those with sac shrinkage (≥5 mm) or failure to regress (<5 mm or expansion) according to sac diameter change. The primary end point was all-cause mortality. Secondary end points were aortic-related mortality (ARM), aortic aneurysm rupture (AAR), and aorta-related secondary intervention. RESULTS There were 549 patients treated by FB-EVAR. Of these, 463 patients (71% male, mean age, 74 ± 8 years) with sequential computed tomography imaging were investigated. Aneurysm extent was thoracoabdominal aortic aneurysms in 328 patients (71%) and abdominal aortic aneurysms in 135 (29%). Sac shrinkage occurred in 270 patients (58%) and failure to regress in 193 patients (42%), including 19 patients (4%) with sac expansion at 1 year. Patients from both groups had similar cardiovascular risk factors, except for younger age among patients with sac shrinkage (73 ± 8 years vs 75 ± 8 years; P < .001). The median follow-up was 38 months (interquartile range, 18-51 months). The 5-year survival estimate was 69% ± 4.1% for the sac shrinkage group and 46% ± 6.2% for the failure to regress group. Survival estimates adjusted for confounders (age, chronic pulmonary obstructive disease, chronic kidney disease, congestive heart failure, and aneurysm extent) revealed a higher hazard of late mortality in patients with failure to regress (adjusted hazard ratio, 1.72; 95% confidence interval, 1.18-2.52; P = .005). The 5-year cumulative incidences of ARM (1.1% vs 3.1%; P = .30), AAR (0.6% vs 2.6%; P = .20), and aorta-related secondary intervention (17.0% ± 2.8% vs 19.0% ± 3.8%) were both comparable between the groups. CONCLUSIONS Aneurysm sac shrinkage at 1 year is common after FB-EVAR and is associated with improved patient survival, whereas sac enlargement affects only a minority of patients. The low incidences of ARM and AAR indicate that failure to regress may serve as a surrogate marker for nonaortic-related death.
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Affiliation(s)
- Thomas Mesnard
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, Houston, TX
| | - Titia A L Sulzer
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, Houston, TX
| | - Lucas Ruiter Kanamori
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, Houston, TX
| | - Dora Babocs
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, Houston, TX
| | - Andrea Vacirca
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, Houston, TX
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, Houston, TX
| | - Safa Savadi
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, Houston, TX
| | - Emanuel R Tenorio
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, Houston, TX
| | - Aleem Mirza
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, Houston, TX
| | - Naveed Saqib
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, Houston, TX
| | - Bernardo Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Thanilla Macedo
- Department of Diagnostic and Interventional Radiology at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ying Huang
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, Houston, TX
| | - Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, Houston, TX.
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Long C, Katsargyris A, Milner R, Verhoeven E. Five-Year Results for Abdominal Aortic Aneurysm Repair with the GORE® EXCLUDER® Device: Insights from the Gore Global Registry for Endovascular Aortic Treatment (GREAT). Ann Vasc Surg 2024; 106:247-254. [PMID: 38815908 DOI: 10.1016/j.avsg.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND The early postoperative benefits of endovascular aneurysm repair (EVAR) have been well established but questions remain regarding its durability at mid-term and long-term time points. Long-term results in real-world use of EVAR outside of randomized trial data are limited. This study used the Global Registry for Endovascular Aortic Treatment registry to explore the 5-year outcomes with the GORE EXCLUDER device in real-world clinical circumstances. METHODS All patients within the Global Registry for Endovascular Aortic Treatment registry who underwent an infrarenal abdominal aortic aneurysm repair with the GORE EXCLUDER device were included in this study. Baseline characteristics and demographic information of the cohort were collected. End points included mortality (all-cause and aneurysm-related), serious endoleaks, aneurysm sac diameter, endograft integrity (fracture, compression, migration), post-EVAR aortic rupture, device-related reintervention, conversion to open repair, graft explantation, and major adverse cardiovascular events. RESULTS A total of 3,216 patients were included in this analysis. The cohort reflected a significantly comorbid population with 46% of patients reaching a Charlson Comorbidity Index score of ≥5. Follow-up at 5 years was 60% of eligible participants. The freedom from aortic-related mortality was at 98.8% and overall survival was 71.2%. Postoperative major adverse cardiovascular events occurred in 49 (1.5%) patients. Device-related intervention through 5 years was 7.2% and the overall serious endoleak rate was 6.8%. Less than 1% of patients required an open conversion/revision and aortic rupture following device placement occurred in 15 (0.5%) patients. Aneurysm sac regression was achieved in 58.1% of patients at 5 years, and stability/absence of growth was observed in 83.6% at 5 years. CONCLUSIONS This study supports the durability of the GORE EXCLUDER device through 5 years with negligible incidence of graft integrity compromise and low aortic/device-related reintervention rates. Furthermore, the efficacy of the device is highlighted with low aortic-related mortality and high sac regression/stability diameter through 5 years.
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Affiliation(s)
- Chandler Long
- Division of Vascular and Endovascular Surgery, Duke University Medical Center, Durham, NC.
| | - Athanasios Katsargyris
- Division of Vascular and Endovascular Surgery, General Hospital & Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Ross Milner
- Division of Vascular Surgery, University of Chicago Medical Center, Chicago, IL
| | - Eric Verhoeven
- Division of Vascular and Endovascular Surgery, General Hospital & Paracelsus Medical University Nuremberg, Nuremberg, Germany
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18
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Konert M, Schmidt A, Branzan D, Wittig T, Scheinert D, Steiner S. ELECT: prospective, randomized trial comparing microvascular plug versus platinum-fibered microcoils for embolization of aneurysm sac side branches before endovascular aortic aneurysm repair. CVIR Endovasc 2024; 7:42. [PMID: 38700601 PMCID: PMC11068722 DOI: 10.1186/s42155-024-00454-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/16/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Preemptive selective embolization of aneurysm sac side branches (ASSBs) has been proposed to prevent type II endoleak after endovascular aortic aneurysm repair (EVAR). This study aimed to explore if an embolization strategy using microvascular plugs (MVP) reduces intervention time and radiation dose compared to platinum-fibered microcoils. Furthermore, the effectiveness of the devices in occluding the treated artery was assessed. METHODS Sixty patients scheduled for EVAR underwent percutaneous preemptive embolization of ASSBs using MVPs or coils after a 1:1 randomization. Follow-up imaging was performed during aortic stentgraft implantation. RESULTS Overall, 170 ASSBs were successfully occluded (83 arteries by MVPs and 87 by coils) and no acute treatment failure occurred. The mean procedure time was significantly lower in the group treated with MVPs (55 ± 4 min) compared to coil occlusion (67 ± 3 min; p = 0.018), which was paralleled by a numerically lower radiation dose (119 Gy/cm2 vs. 140 Gy/cm2; p = 0.45). No difference was found for contrast agent use (34 ml MVP group vs 35 ml coil group; p = 0.87). At follow-up, reopening of lumbar arteries was seen in nine cases (four after coil embolization; five after MVPs). CONCLUSION Both microvascular plugs and coils can be effectively used for preemptive embolization of aneurysm sac side branches before EVAR. Use of plugs offers a benefit in terms of intervention time. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03842930 Registered 15 February 2019.
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Affiliation(s)
- Manuela Konert
- Division of Angiology, Department of Angiology, University Hospital Leipzig, Liebigstraße 18, 04103, Leipzig, Germany.
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Center Munich at the University of Leipzig and University Hospital Leipzig, Leipzig, Germany.
| | - Andrej Schmidt
- Division of Angiology, Department of Angiology, University Hospital Leipzig, Liebigstraße 18, 04103, Leipzig, Germany
| | - Daniela Branzan
- Department of Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Center Munich at the University of Leipzig and University Hospital Leipzig, Leipzig, Germany
| | - Tim Wittig
- Division of Angiology, Department of Angiology, University Hospital Leipzig, Liebigstraße 18, 04103, Leipzig, Germany
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Center Munich at the University of Leipzig and University Hospital Leipzig, Leipzig, Germany
| | - Dierk Scheinert
- Division of Angiology, Department of Angiology, University Hospital Leipzig, Liebigstraße 18, 04103, Leipzig, Germany
| | - Sabine Steiner
- Division of Angiology, Department of Angiology, University Hospital Leipzig, Liebigstraße 18, 04103, Leipzig, Germany
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Center Munich at the University of Leipzig and University Hospital Leipzig, Leipzig, Germany
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19
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Holden A, Hill AA, Khashram M, Heyligers JMM, Wiersema AM, Hayes PD, Reijnen MMPJ. One-year follow-up after active aortic aneurysm sac treatment with shape memory polymer devices during endovascular aneurysm repair. J Vasc Surg 2024; 79:1090-1100.e4. [PMID: 38185214 DOI: 10.1016/j.jvs.2023.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/28/2023] [Accepted: 12/30/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE To determine the safety and efficacy of treating abdominal aortic aneurysm (AAA) sacs with polyurethane shape memory polymer (SMP) devices during endovascular aneurysm repair (EVAR), using a technique to fully treat the target lumen after endograft placement (aortic flow volume minus the endograft volume). SMP devices self-expand in the sac to form a porous scaffold that supports thrombosis throughout its structure. METHODS Two identical prospective, multicenter, single-arm studies were conducted in New Zealand and the Netherlands. The study population was adult candidates for elective EVAR of an infrarenal AAA (diameter of ≥55 mm in men and ≥50 mm in women). Key exclusion criteria were an inability to adequately seal a common iliac artery aneurysm, patent sac feeding vessels of >4 mm, and a target lumen volume of <20 mL or >135 mL. Target lumen volumes were estimated by subtracting endograft volumes from preprocedural imaging-based flow lumen volumes. SMP devices were delivered immediately after endograft deployment via a 6F sheath jailed in a bowed position in the sac. The primary efficacy end point was technical success, defined as filling the actual target lumen volume with fully expanded SMP at the completion of the procedure. Secondary efficacy outcome measures during follow-up were the change in sac volume and diameter, rate of type II endoleak and type I or III endoleaks, and the rate of open repair and related reinterventions, with data collection at 30 days, 6 months, and 1 year (to date). Baseline sac volumes and diameters for change in sac size analyses were determined from 30-day imaging studies. Baseline and follow-up volumes were normalized by subtraction of the endograft volume. RESULTS Of 34 patients treated with SMP devices and followed per protocol, 33 patients were evaluable at 1 year. Preprocedural aneurysm volume was 181.4 mL (95% confidence interval [CI], 150.7-212.1 mL) and preprocedural aneurysm diameter was 60.8 mm (95% CI, 57.8-63.9 mm). The target lumen volume was 56.3 mL (95% CI, 46.9-65.8 mL). Technical success was 100% and the ratio of SMP fully expanded volume to estimated target lumen volume was 1.4 ± 0.3. Baseline normalized sac volume and diameter were 140.7 mL (95% CI, 126.6-154.9 mL) and 61.0 mm (95% CI, 59.7-62.3 mm). The adjusted mean percentage change in normalized volume at 1 year was -28.8% (95% CI, -35.3 to -22.3%; P < .001). The adjusted mean change in sac diameter at 1 year was -5.9 mm (95% CI, -7.5 to -4.4 mm; P < .001). At 1 year, 81.8% of patients (95% CI, 64.5%-93.0%) achieved a ≥10% decrease in normalized volume and 57.6% of patients (95% CI, 39.2%-74.5%) achieved a ≥5 mm decrease in diameter. No device- or study procedure-related major adverse events occurred through 1 year after the procedure. CONCLUSIONS Treatment of AAA sacs with SMP devices during EVAR resulted in significant sac volume and diameter regression at 1 year with an acceptable safety profile in this prospective study.
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Affiliation(s)
- Andrew Holden
- Department of Interventional Radiology, Auckland City Hospital, Auckland, New Zealand.
| | - Andrew A Hill
- Vascular Services, Auckland City Hospital, Auckland, New Zealand
| | - Manar Khashram
- Department of Vascular & Endovascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Jan M M Heyligers
- Department of Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Arno M Wiersema
- Department of Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands
| | | | - Michel M P J Reijnen
- Department of Surgery, Rijnstate, Arnhem, The Netherlands; Multi-Modality Medical Imaging Group, University of Twente, Enschede, The Netherlands
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20
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Jessula S, Cote C, Khoury M, DeCarlo C, Bellomo TR, Grant-Gorveatt A, Herman C, Smith M, Dua A, Eagleton M, Casey P, Zacharias N. Local Anesthesia for Endovascular Repair of Abdominal Aortic Aneurysm Allows for Accurate Graft Deployment with Durable Results. Ann Vasc Surg 2024; 102:64-73. [PMID: 38301848 DOI: 10.1016/j.avsg.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/03/2023] [Accepted: 11/09/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Local anesthesia (LA) is sparsely used in endovascular aneurysm repair (EVAR) despite short-term benefit, likely secondary to concerns over patient movement preventing accurate endograft deployment. The objective of this study is to examine the association between anesthesia type and endoleak, sac regression, reintervention, and mortality. METHODS The Vascular Quality Initiative database was queried for all EVAR cases from 2014 to 2022. Patients were included if they underwent percutaneous elective EVAR with anatomical criteria within instructions for use of commercially approved endografts. Multivariable logistic regression with propensity score weighting was used to determine the association between anesthesia type on the risk of any endoleak noted by intraoperative completion angiogram and sac regression. Multivariable survival analysis with propensity score weighting was used to determine the association between anesthesia type and endoleak at 1 year, long-term reintervention, and mortality. RESULTS Thirteen thousand nine hundred thirty two EVARs met inclusion criteria: 1,075 (8%) LA and 12,857 (92%) general anesthesia (GA). On completion angiogram, LA was associated with fewer rates of any endoleaks overall (16% vs. 24%, P < 0.001). On multivariable analysis with propensity score weighting, LA was associated with similar adjusted odds of any endoleak on intraoperative completion angiogram (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.47-0.68) as well as combined type 1a and type 1b endoleaks (OR 0.72, 95% CI 0.47-1.09). Follow-up computed tomography imaging at 1 year was available for 4,892 patients, 377 (8%) LA and 4,515 (92%) GA. At 1 year, LA was associated with similar rate of freedom from any endoleaks compared to GA (0.66 [95% CI 0.63-0.69] vs. 0.71 [95% CI 0.70-0.72], P = 0.663) and increased rates of sac regression (50% vs. 45%, P = 0.040). On multivariable analysis with propensity score weighting, LA and GA were associated with similar adjusted odds of sac regression (OR 1.22, 95% CI 0.97-1.55). LA and GA had similar rates of endoleak at 1 year (hazard ratio [HR] 0.14, 95% CI 0.63-1.07); however, LA was associated with decreased hazards of combined type 1a and 1b endoleaks at 1 year (HR 0.87, 95% CI 0.80-0.96). LA and GA had similar adjusted long-term reintervention rate (HR 0.77, 95% CI 0.44-1.38) and long-term mortality (HR 1.100, 95% CI 079-1.25). CONCLUSIONS LA is not associated with increased adjusted rates of any endoleak on completion angiogram or at 1-year follow-up compared to GA. LA is associated with decreased adjusted rates of type 1a and type 1b endoleak at 1 year, but similar rates of sac regression, long-term reintervention, and mortality. Concerns for accurate graft deployment should not preclude use of LA and LA should be increasingly considered when deciding on anesthetic type for standard elective EVAR.
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Affiliation(s)
- Samuel Jessula
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, NS.
| | - Claudia Cote
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, NS
| | - Mitri Khoury
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Tiffany R Bellomo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alexa Grant-Gorveatt
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, NS
| | - Christine Herman
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, NS
| | - Matthew Smith
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, NS
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Matthew Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Patrick Casey
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, NS
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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21
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Zettervall SL, Schanzer A. Surveillance after EVAR Should Continue to Be a Priority. Eur J Vasc Endovasc Surg 2024; 67:701-702. [PMID: 38754944 DOI: 10.1016/j.ejvs.2024.01.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/15/2024] [Indexed: 05/18/2024]
Affiliation(s)
- Sara L Zettervall
- University of Washington, Division of Vascular Surgery, Seattle, WA, USA.
| | - Andres Schanzer
- UMass Chan Medical School, Division of Vascular Surgery, Worcester, MA, USA. https://twitter.com/AndresSchanzer
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22
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Rastogi V, Sulzer TAL, de Bruin JL, Oliveira-Pinto J, Alberga AJ, Hoeks SE, Bastos Goncalves F, Ten Raa S, Josee van Rijn M, Akkersdijk GP, Fioole B, Verhagen HJM. Aneurysm Sac Dynamics and its Prognostic Significance Following Fenestrated and Branched Endovascular Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2024; 67:728-736. [PMID: 37995962 DOI: 10.1016/j.ejvs.2023.11.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 10/14/2023] [Accepted: 11/16/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE This study aimed to assess aneurysm sac dynamics and its prognostic significance following fenestrated and branched endovascular aneurysm repair (F/BEVAR). METHODS Patients undergoing F/BEVAR for degenerative complex aortic aneurysm from 2008 to 2020 at two large vascular centres with two imaging examinations (30 day and one year) were included. Patients were categorised as regression and non-regression, determined by the proportional volume change (> 5%) at one year compared with 30 days. All cause mortality and freedom from graft related events were assessed using Kaplan-Meier methods. Factors associated with non-regression at one year and aneurysm sac volume over time were examined for FEVAR and BEVAR independently using multivariable logistic regression and linear mixed effects modelling. RESULTS One hundred and sixty-five patients were included: 122 FEVAR, of whom 34% did not regress at one year imaging (20% stable, 14% expansion); and 43 BEVAR, of whom 53% failed to regress (26% stable, 28% expansion). Following F/BEVAR, after risk adjusted analysis, non-regression was associated with higher risk of all cause mortality within five years (hazard ratio [HR] 2.56, 95% confidence interval [CI] 1.09 - 5.37; p = .032) and higher risk of graft related events within five years (HR 2.44, 95% CI 1.10 - 5.26; p = .029). Following multivariable logistic regression, previous aortic repair (odds ratio [OR] 2.56, 95% CI 1.11 - 5.96; p = .029) and larger baseline aneurysm diameter (OR/mm 1.04, 95% CI 1.00 - 1.09; p = .037) were associated with non-regression at one year, whereas smoking history was inversely associated with non-regression (OR 0.21, 95% CI 0.04 - 0.96; p = .045). Overall following FEVAR, aneurysm sac volume decreased significantly up to two years (baseline vs. two year, 267 [95% CI 250 - 285] cm3vs. 223 [95% CI 197 - 248] cm3), remaining unchanged thereafter. Overall following BEVAR, aneurysm sac volume remained stable over time. CONCLUSION Like infrarenal EVAR, non-regression at one year imaging is associated with higher five year all cause mortality and graft related events risks after F/BEVAR. Following FEVAR for juxtarenal aortic aneurysm, aneurysm sacs generally displayed regression (66% at one year), whereas after BEVAR for thoraco-abdominal aortic aneurysm, aneurysm sacs displayed a concerning proportion of growth at one year (28%), potentially suggesting a persistent risk of rupture and consequently requiring intensified surveillance following BEVAR. Future studies will have to elucidate how to improve sac regression following complex EVAR, and whether the high expansion risk after BEVAR is due to advanced disease extent.
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Affiliation(s)
- Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands.
| | - Titia A L Sulzer
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - José Oliveira-Pinto
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Angiology and Vascular Surgery, Centro Hospitalar São João, Porto, Portugal
| | - Anna J Alberga
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Sanne E Hoeks
- Department of Anaesthetics, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Frederico Bastos Goncalves
- NOVA Medical School - Faculdade de Ciências Médicas (NMS|FCM), Universidade Nova de Lisboa, Lisbon, Portugal; Hospital CUF Tejo, Lisbon, Portugal
| | - Sander Ten Raa
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Marie Josee van Rijn
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - George P Akkersdijk
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
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23
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Girolamo AD, Ascione M, Miceli F, Mohseni A, Pranteda C, Sirignano P, Taurino M, di Marzo L, Mansour W. Clinical and Radiological Outcomes of Accessory Renal Artery Exclusion during Endovascular Repair of Abdominal Aortic Aneurysms. Diagnostics (Basel) 2024; 14:864. [PMID: 38732277 PMCID: PMC11083523 DOI: 10.3390/diagnostics14090864] [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: 02/22/2024] [Revised: 04/06/2024] [Accepted: 04/18/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Accessory renal arteries (ARAs) frequently coexist with abdominal aortic aneurysms (AAA) and can influence treatment. This study aimed to retrospectively analyze the ARA's exclusion effect on patients undergoing standard endovascular aneurysm repair for AAA. METHODS The study focused on medium- and long-term outcomes, including type II endoleak, aneurysmal sac changes, mortality, reoperation rates, renal function, and infarction post-operatively. RESULTS 76 patients treated with EVAR for AAA were included. One hundred and two ARAs were identified: 69 originated from the neck, 30 from the sac, and 3 from the iliac arteries. The ARA treatment was embolization in 15 patients and coverage in 72. Technical success was 100%. One-month post-operative computed tomography angiography (CTA) revealed that 76 ARAs (74.51%) were excluded. Thirty-day complications included renal deterioration in 7 patients (9.21%) and a blood pressure increase in 15 (19.73%). During follow-up, 16 patients (21.05%) died, with three aneurysm-related deaths (3.94%). ARA-related type II endoleak (T2EL) was significantly associated with the ARA's origin in the aneurysmatic sac. Despite reinterventions were not significantly linked to any factor, post-operative renal infarction was correlated with an ARA diameter greater than 3 mm and ARA embolization. CONCLUSION ARAs can influence EVAR outcomes, with anatomical and procedural factors associated with T2EL and renal infarction. Further studies are needed to optimize the management of ARAs during EVAR.
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Affiliation(s)
- Alessia Di Girolamo
- Vascular and Endovascular Surgery Division, Department of General Surgery and Surgical Specialties, Policlinico Umberto I, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (A.D.G.); (M.A.); (F.M.); (L.d.M.)
| | - Marta Ascione
- Vascular and Endovascular Surgery Division, Department of General Surgery and Surgical Specialties, Policlinico Umberto I, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (A.D.G.); (M.A.); (F.M.); (L.d.M.)
| | - Francesca Miceli
- Vascular and Endovascular Surgery Division, Department of General Surgery and Surgical Specialties, Policlinico Umberto I, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (A.D.G.); (M.A.); (F.M.); (L.d.M.)
| | - Alireza Mohseni
- Faculty of Medicine and Surgery, Sapienza University of Rome, Viale Regina Elena, 324, 00161 Rome, Italy;
| | - Chiara Pranteda
- Vascular and Endovascular Surgery Unit, Sant’Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1035/1039, 00189 Rome, Italy; (C.P.); (P.S.); (M.T.)
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Sant’Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1035/1039, 00189 Rome, Italy; (C.P.); (P.S.); (M.T.)
| | - Maurizio Taurino
- Vascular and Endovascular Surgery Unit, Sant’Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1035/1039, 00189 Rome, Italy; (C.P.); (P.S.); (M.T.)
| | - Luca di Marzo
- Vascular and Endovascular Surgery Division, Department of General Surgery and Surgical Specialties, Policlinico Umberto I, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (A.D.G.); (M.A.); (F.M.); (L.d.M.)
| | - Wassim Mansour
- Vascular and Endovascular Surgery Division, Department of General Surgery and Surgical Specialties, Policlinico Umberto I, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (A.D.G.); (M.A.); (F.M.); (L.d.M.)
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24
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Vos CG, Fouad F, Dieleman IM, Schuurmann RC, de Vries JPP. Importance of sac regression after EVAR and the role of EndoAnchors. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:99-105. [PMID: 38551514 DOI: 10.23736/s0021-9509.24.12992-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
The initial success and widespread adoption of endovascular aneurysm repair (EVAR) for the treatment of abdominal aortic aneurysms have been tempered by numerous reports of secondary interventions and increased long-term mortality compared with open repair. Over the past decade, several studies on postoperative sac dynamics after EVAR have suggested that the presence of sac regression is a benign feature with a favorable prognosis. Conversely, increasing sacs and even stable sacs can be indicators of more unstable sac behavior with worse outcomes in the long-term. Endoleaks were initially perceived as the main drivers of sac behavior. However, the observation that sac regression can occur in the presence of endoleaks, and vice versa - increasing sacs without evidence of endoleak - on imaging studies, suggests the involvement of other contributing factors. These factors can be divided into anatomical factors, patient characteristics, sac thrombus composition, and device-related factors. The shift of interest away from especially type 2 endoleaks is further supported by promising results with the use of EndoAnchors regarding postoperative sac behavior. This review provides an overview of the existing literature on the implications and known risk factors of post-EVAR sac behavior, describes the accurate measurement of sac behavior, and discusses the use of EndoAnchors to promote sac regression.
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Affiliation(s)
- Cornelis G Vos
- Department of Surgery, Martini Hospital, Groningen, the Netherlands
| | - Fatima Fouad
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands -
| | - Isabel M Dieleman
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Richte Cl Schuurmann
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Jean-Paul Pm de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
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25
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Kyrou IE, Antonopoulos CN, Antoniou GA. Time Dependent Correlation Between Sac Behaviour and Re-intervention after Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2024; 67:612-619. [PMID: 37992984 DOI: 10.1016/j.ejvs.2023.11.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 10/14/2023] [Accepted: 11/16/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE This study aimed to investigate the correlation between aneurysm sac behaviour and time to re-intervention after endovascular aneurysm repair (EVAR). METHODS A retrospective observational cohort study of patients who underwent EVAR at a single centre between January 2008 and November 2011 and who were followed up for a mean of 6.6 ± 2.9 years was conducted. Based on sac appearances on pre-operative imaging and imaging at the end of follow up, patients were stratified into two groups: (1) sac regression; and (2) no sac regression. The no sac regression group was further subdivided into stable sac group and sac expansion group. Sac regression and expansion throughout follow up were defined as a decrease or increase in the abdominal aortic aneurysm sac diameter of ≥ 5 mm compared with the pre-operative size. A Cox proportional hazards model using multiple failure per subject data was used to identify sac behaviour as a predictor of re-intervention free time. RESULTS Patients with sac regression had a higher probability of freedom from re-intervention compared with those with a stable or expanding aneurysm sac (94%, 57%, and 16% at 12 years, respectively; log rank, p < .001). Mean time to re-intervention was 11.3 years for the sac regression group, 8.8 years for the stable sac group, and 5.0 years for the sac expansion group (p < .001). In the stable sac group, the risk of re-intervention increased sharply six years after EVAR, whereas in the sac expansion group a sharp rise in re-intervention was noted 3.5 years after EVAR, reaching a plateau after year 6. CONCLUSION A time dependent correlation between aneurysm sac behaviour and re-intervention was found. Such findings have implications for surveillance strategies.
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Affiliation(s)
- Ioanna E Kyrou
- Department of Vascular and Endovascular Surgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Constantine N Antonopoulos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK; Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.
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Gentsu T, Yamaguchi M, Sasaki K, Kawasaki R, Horinouchi H, Fukuda T, Miyamoto N, Mori T, Sakamoto N, Uotani K, Taniguchi T, Koda Y, Yamanaka K, Takahashi H, Okada K, Hayashi T, Watanabe T, Nomura Y, Matsushiro K, Ueshima E, Okada T, Sugimoto K, Murakami T. Side branch embolization before endovascular abdominal aortic aneurysm repair to prevent type II endoleak: A prospective multicenter study. Diagn Interv Imaging 2024:S2211-5684(24)00079-2. [PMID: 38503637 DOI: 10.1016/j.diii.2024.03.003] [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: 01/15/2024] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE The purpose of the study was to evaluate the efficacy and safety of pre-emptive transcatheter arterial embolization (P-TAE) of aortic side branches to prevent type II endoleak in patients with abdominal aortic aneurysm after endovascular abdominal aneurysm repair (EVAR). MATERIALS AND METHODS This multicenter, prospective, single-arm trial enrolled 100 patients with abdominal aortic aneurysm from nine hospitals between 2018 and 2021. There were 85 men and 15 women, with a mean age of 79.6 ± 6.0 (standard deviation) years (range: 65-97 years). P-TAE was attempted for patent aortic side branches, including the inferior mesenteric artery, lumbar arteries, and other branches. The primary endpoint was late type II endoleak incidence at 6 months post-repair. Secondary endpoints included changes in aneurysmal sac diameter at 6- and 12 months, complications, re-intervention, and aneurysm-related mortality. Aneurysm sac changes at 6- and 12 months was compared between the late and no-late type II endoleak groups. RESULTS Coil embolization was successful in 80.9% (321/397) of patent aortic side branches, including 86.3% of the inferior mesenteric arteries, 80.3% of lumbar arteries, and 55.6% of other branches without severe adverse events. Late type II endoleak incidence at 6 months was 8.9% (8/90; 95% confidence interval: 3.9-16.8%). Aneurysm sac shrinkage > 5 mm was observed in 41.1% (37/90) and 55.3% (47/85) of the patients at 6- and 12-months post-EVAR, respectively. Patients with late type II endoleak had less aneurysm sac shrinkage than those without type II endoleak at 12 months (-0.2 mm vs. -6.0 mm; P = 0.040). No patients required re-intervention for type II endoleak, and no aneurysm-related mortalities occurred. CONCLUSION P-TAE is safe and effective in preventing type II endoleak, leading to early sac shrinkage at 12 months following EVAR.
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Affiliation(s)
- Tomoyuki Gentsu
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan
| | - Masato Yamaguchi
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan.
| | - Koji Sasaki
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan
| | - Ryota Kawasaki
- Department of Diagnostic and Interventional Radiology, Hyogo Prefectural Harima-Himeji General Medical Center, Himeji, Hyogo 670-8560, Japan
| | - Hiroki Horinouchi
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Osaka 565-8565, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Osaka 565-8565, Japan
| | - Naokazu Miyamoto
- Department of Radiology, Kita-harima Medical Center, Ono, Hyogo 675-1323, Japan
| | - Takeki Mori
- Department of Radiology, Japanese Red Cross Kobe Hospital, Kobe, Hyogo 651-0073, Japan
| | - Noriaki Sakamoto
- Department of Diagnostic and Interventional Radiology, Kakogawa Central City Hospital, Kakogawa, Hyogo 675-8520, Japan
| | - Kensuke Uotani
- Department of Radiology, Hyogo Prefectural Awaji Medical Center, Sumoto, Hyogo 656-0021, Japan
| | | | - Yojiro Koda
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Katsuhiro Yamanaka
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Hiroaki Takahashi
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Kenji Okada
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Taro Hayashi
- Department of Cardiovascular Surgery, Akashi Medical Center, Akashi, Hyogo 673-0896, Japan
| | - Toshitaka Watanabe
- Department of Cardiovascular Surgery, Akashi Medical Center, Akashi, Hyogo 673-0896, Japan
| | - Yoshikatsu Nomura
- Department of Cardiovascular Surgery, Hyogo Prefectural Harima-Himeji General Medical Center, Himeji, Hyogo 670-8560, Japan
| | - Keigo Matsushiro
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan
| | - Eisuke Ueshima
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan
| | - Takuya Okada
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan
| | - Koji Sugimoto
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan
| | - Takamichi Murakami
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan
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27
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Tinelli G, D'Oria M, Sica S, Mani K, Rancic Z, Resch TA, Beccia F, Azizzadeh A, Da Volta Ferreira MM, Gargiulo M, Lepidi S, Tshomba Y, Oderich GS, Haulon S. The sac evolution imaging follow-up after endovascular aortic repair: An international expert opinion-based Delphi consensus study. J Vasc Surg 2024:S0741-5214(24)00424-5. [PMID: 38462062 DOI: 10.1016/j.jvs.2024.03.007] [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: 12/05/2023] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE Management of follow-up protocols after endovascular aortic repair (EVAR) varies significantly between centers and is not standardized according to sac regression. By designing an international expert-based Delphi consensus, the study aimed to create recommendations on follow-up after EVAR according to sac evolution. METHODS Eight facilitators created appropriate statements regarding the study topic that were voted, using a 4-point Likert scale, by a selected panel of international experts using a three-round modified Delphi consensus process. Based on the experts' responses, only those statements reaching a grade A (full agreement ≥75%) or B (overall agreement ≥80% and full disagreement <5%) were included in the final document. RESULTS One-hundred and seventy-four participants were included in the final analysis, and each voted the initial 29 statements related to the definition of sac regression (Q1-Q9), EVAR follow-up (Q10-Q14), and the assessment and role of sac regression during follow-up (Q15-Q29). At the end of the process, 2 statements (6.9%) were rejected, 9 statements (31%) received a grade B consensus strength, and 18 (62.1%) reached a grade A consensus strength. Of 27 final statements, 15 (55.6%) were classified as grade I, whereas 12 (44.4%) were classified as grade II. Experts agreed that sac regression should be considered an important indicator of EVAR success and always be assessed during follow-up after EVAR. CONCLUSIONS Based on the elevated strength and high consistency of this international expert-based Delphi consensus, most of the statements might guide the current clinical management of follow-up after EVAR according to the sac regression. Future studies are needed to clarify debated issues.
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Affiliation(s)
- Giovanni Tinelli
- Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Trieste, Italy
| | - Simona Sica
- Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Zoran Rancic
- Department of Vascular Surgery, University of Zurich, Zurich, Switzerland
| | - Timothy Andrew Resch
- Department of Vascular Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Flavia Beccia
- Section of Hygiene and Public Health, Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ali Azizzadeh
- Division of Vascular Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Mauro Gargiulo
- Vascular Surgery University of Bologna, Vascular Surgery Unit IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Trieste, Italy
| | - Yamume Tshomba
- Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Stéphan Haulon
- Hôpital Marie Lannelongue, GHPSJ, Université Paris Saclay, Paris, France
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28
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Ueda R, Esaki J, Tsubota H, Honda M, Kudo M, Nakatsuma K, Kato M, Okabayashi H. Impact of the Lumbar Arteries on Aneurysm Diameter and Type 2 Endoleak after Endovascular Aneurysm Repair. Ann Vasc Surg 2024; 100:138-147. [PMID: 38141967 DOI: 10.1016/j.avsg.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Prophylactic embolization of the inferior mesenteric artery (IMA) during endovascular aneurysm repair (EVAR) is recommended to prevent type 2 endoleak (T2EL). However, the impact of patent lumbar arteries (LAs) on T2ELs and aneurysm diameter has not been elucidated. METHODS Fifty-seven consecutive patients who underwent EVAR at our institution between January 2013 and September 2022 and whose IMA had been occluded preoperatively or newly occluded postoperatively were included in the study. Predictive factors for aneurysm sac enlargement, sac shrinkage, and T2EL were investigated. RESULTS T2ELs occurred in 22.8% of the patients. The 4-year cumulative incidence rates of sac enlargement and shrinkage were 6.7% and 64.6%, respectively. The number of postoperative patent LAs was identified as a risk factor for T2ELs (95% confidence interval [CI]: 1.54-12.7, P = 0.0065). The number of postoperative patent LAs was found to be a significant predictor of sac enlargement (adjusted hazard ratio [AHR] 3.15, 95% CI: 1.43-6.96, P = 0.0045) and shrinkage (AHR 0.63, 95% CI: 0.43-0.91, P = 0.014). CONCLUSIONS The current study demonstrated that the number of postoperative patent LAs had a significant impact on the development of T2ELs and the change in aneurysm diameter in patients in whom the IMA was occluded after EVAR.
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Affiliation(s)
- Ryoma Ueda
- Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, Kyoto, Japan.
| | - Jiro Esaki
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hideki Tsubota
- Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Masanori Honda
- Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Masafumi Kudo
- Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Kenji Nakatsuma
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Masashi Kato
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Hitoshi Okabayashi
- Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, Kyoto, Japan
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29
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Squizzato F, Antonello M, Modena M, Forcella E, Colacchio EC, Grego F, Piazza M. Fate of primary determinate and indeterminate target vessel endoleaks after fenestrated-branched endovascular aortic repair. J Vasc Surg 2024; 79:207-216.e4. [PMID: 37804955 DOI: 10.1016/j.jvs.2023.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/08/2023] [Accepted: 09/24/2023] [Indexed: 10/09/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the outcomes of primary determinate and indeterminate target vessel endoleaks (TVELs) after fenestrated-branched endovascular aortic repair (F-BEVAR). METHODS We conducted a single-center retrospective study (2014-2023) on F-BEVAR for thoracoabdominal (TAAAs) or pararenal aortic aneurysms (PRAAs). TVELs were classified as "primary" if present at the first postoperative computed tomography angiogram. Endoleaks were defined "determinate" (dELs) if the cause (type Ic or IIIc) and implicated target vessel were identifiable and "indeterminate" (iELs) if contrast enhancement was detectable at the level of fenestrations/branches without any evident source. Endoleaks involving multiple inflows (type II and target vessels) were defined as "complex" (cELs). Endpoints were endoleak spontaneous resolution, 1-year aneurysm sac failure to regress (>5 mm diameter decrease), and 4-year endoleak-related secondary interventions. Kaplan-Meier estimates and Cox regression were used for the analysis. RESULTS There were 142 patients with JRAAs/PRAAs (n = 85; 60%) or TAAAs (n = 57; 40%), with 513 target arteries incorporated through a fenestration (n = 294; 57%) or directional branch (n = 219; 43%). Fifty-nine primary TVELs (12%) were identified in 35 patients (25%), a dEL in 20 patients (14%) and iEL in 15 (11%); 22 (15%) had a determinate or indeterminate cEL. Overall spontaneous resolution rate was 75% (95% confidence interval [CI], 51%-87%) at 4 years. cELs (odds ratio [OR], 5.00; 95% CI, 1.10-49.4; P < .001) and iELs after BEVAR (OR, 9.43; 95% CI, 3.41-56.4; P = .002) were more likely to persist >6 months, and persistent forms were associated with sac failure to regress at 1 year (OR, 1.72; 95% CI, 1.03-12.59; P = .040). Overall freedom from endoleak-related reinterventions was 85% (95% CI, 79%-92%) at 4 years, 92% (95% CI, 87%-97%) for those without primary TVELs and 62% (95% CI, 46%-84%) for those with any primary TVEL (P < .001). In particular, cELs (hazard ratio, 1.94; 95% CI, 1.4-18.81; P = .020) were associated with an increased need for reintervention. In case a secondary intervention was needed, iEL or cEL had an increased risk for multiple secondary procedures (hazard ratio, 2.67; 95% CI, 1.22-10.34; P = .034). CONCLUSIONS Primary TVELs are frequent after F-BEVAR, and a clear characterization of the endoleak source by computed tomography angiogram is not possible in 40% of patients. Most primary TVELs spontaneously resolve, but during follow-up, patients with any primary TVEL experience a worsened freedom from endoleak-related reinterventions that is mostly driven by persistence of cELs and post-BEVAR iELs. Multiple secondary procedures may be required in case of iELs or cELs.
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Affiliation(s)
- Francesco Squizzato
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Padua, Italy.
| | - Michele Antonello
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Padua, Italy
| | - Matteo Modena
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Padua, Italy
| | - Edoardo Forcella
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Padua, Italy
| | - Elda Chiara Colacchio
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Padua, Italy
| | - Franco Grego
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Padua, Italy
| | - Michele Piazza
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Padua, Italy
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30
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Rastogi V, O'Donnell TFX, Marcaccio CL, Patel PB, Varkevisser RRB, Yadavalli SD, de Bruin JL, Verhagen HJM, Patel VI, Schermerhorn ML. One-year aneurysm-sac dynamics are associated with reinterventions and rupture following infrarenal endovascular aneurysm repair. J Vasc Surg 2024; 79:269-279. [PMID: 37844849 DOI: 10.1016/j.jvs.2023.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 10/07/2023] [Accepted: 10/11/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE One-year aneurysm sac changes have previously been found to be associated with mortality and may have the potential to guide personalized follow-up following endovascular aneurysm repair (EVAR). In this study, we examined the association of these early sac changes with long-term reintervention and rupture. METHODS We identified all patients undergoing first-time EVAR for intact abdominal aortic aneurysm between 2003 and 2018 in the Vascular Quality Initiative with linkage to Medicare claims for long-term outcomes. We included patients with an imaging study at 1 year postoperatively. Aneurysm sac behavior was defined as per the Society for Vascular Surgery guidelines: stable sac (<5 mm change), sac regression (≥5 mm), and sac expansion (≥5 mm). Outcomes included mortality, reintervention, and rupture within 8 years, which were assessed with Kaplan-Meier methods and multivariable Cox regression analysis. Secondarily, we utilized polynomial spline interpolation to demonstrate the continuous relationship of diameter change to 8-year hazard of reintervention, rupture, or mortality as a composite outcome. RESULTS Of 31,185 EVAR patients, 16,102 (52%) had an imaging study at 1 year and were included in this study. At 1 year, 44% of sacs remained stable, 49% regressed, and 6.2% displayed expansion. Following risk adjustment, compared with a stable sac at 1 year, sac regression was associated with lower 8-year mortality (49% vs 53%; hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.85-0.99; P = .036), reintervention rate (8.9% vs 15%; HR, 0.58; 95% CI, 0.50-0.68; P < .001), and rupture rate (2.0% vs 4.0%; HR, 0.45; 95%CI, 0.29-0.69; P < .001). Conversely, compared with a stable sac, sac expansion was associated with higher 8-year mortality (64% vs 53%; HR, 1.31; 95% CI, 1.14-1.51; P < .001) and reintervention rate (27% vs 15%; HR, 1.98; 95% CI, 1.57-2.51; P < .001), but similar risk of rupture (7.2% vs 4.0%; HR, 1.61; 95% CI, 0.88-2.96; P = .12). Polynomial spline interpolation demonstrated that, compared with no diameter change at 1 year, increased sac regression was associated with an incrementally lower risk of late outcomes, whereas increased sac expansion was associated with an incrementally higher risk of late outcomes. CONCLUSIONS Following EVAR, compared with a stable sac at 1-year imaging, sac regression and expansion are associated with a lower and higher risk respectively of long-term mortality, reinterventions, and ruptures. Moreover, the amount of regression or expansion seems to be incrementally associated with these late outcomes, too. Future studies are needed to determine how to improve 1-year sac regression, and whether it is safe to extend follow-up intervals for patients with regressing sacs.
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Affiliation(s)
- Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Thomas F X O'Donnell
- Division of Vascular Surgery and Endovascular Interventions, Columbia University Irving Medical Center, New York, NY
| | - Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of General Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Rens R B Varkevisser
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - 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
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, Columbia University Irving Medical Center, New York, NY
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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31
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Vanmaele A, Bouwens E, Hoeks SE, Kindt A, Lamont L, Fioole B, Moelker A, Ten Raa S, Hussain B, Oliveira-Pinto J, Ijpma AS, van Lier F, Akkerhuis KM, Majoor-Krakauer DF, Hankemeier T, de Rijke Y, Verhagen HJ, Boersma E, Kardys I. Targeted proteomics and metabolomics for biomarker discovery in abdominal aortic aneurysm and post-EVAR sac volume. Clin Chim Acta 2024; 554:117786. [PMID: 38246209 DOI: 10.1016/j.cca.2024.117786] [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: 05/10/2023] [Revised: 12/27/2023] [Accepted: 01/14/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND AND AIMS Abdominal aortic aneurysm (AAA) patients undergo uniform surveillance programs both leading up to, and following surgery. Circulating biomarkers could play a pivotal role in individualizing surveillance. We applied a multi-omics approach to identify relevant biomarkers and gain pathophysiological insights. MATERIALS AND METHODS In this cross-sectional study, 108 AAA patients and 200 post-endovascular aneurysm repair (post-EVAR) patients were separately investigated. We performed partial least squares regression and ingenuity pathway analysis on circulating concentrations of 96 proteins (92 Olink Cardiovascular-III panel, 4 ELISA-assays) and 199 metabolites (measured by LC-TQMS), and their associations with CT-based AAA/sac volume. RESULTS The median (25th-75th percentile) maximal diameter was 50.0 mm (46.0, 53.0) in the AAA group, and 55.4 mm (45.0, 64.2) in the post-EVAR group. Correcting for clinical characteristics in AAA patients, the aneurysm volume Z-score differed 0.068 (95 %CI: (0.042, 0.093)), 0.066 (0.047, 0.085) and -0.051 (-0.064, -0.038) per Z-score valine, leucine and uPA, respectively. After correcting for clinical characteristics and orthogonalization in the post-EVAR group, the sac volume Z-score differed 0.049 (0.034, 0.063) per Z-score TIMP-4, -0.050 (-0.064, -0.037) per Z-score LDL-receptor, -0.051 (-0.062, -0.040) per Z-score 1-OG/2-OG and -0.056 (-0.066, -0.045) per Z-score 1-LG/2-LG. CONCLUSIONS The branched-chain amino acids and uPA were related to AAA volume. For post-EVAR patients, LDL-receptor, monoacylglycerols and TIMP-4 are potential biomarkers for sac volume. Additionally, distinct markers for sac change were identified.
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Affiliation(s)
- Alexander Vanmaele
- Department of Cardiology, Thorax Centre, Cardiovascular Institute, Erasmus MC, Rotterdam, the Netherlands; Department of Vascular Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Elke Bouwens
- Department of Cardiology, Thorax Centre, Cardiovascular Institute, Erasmus MC, Rotterdam, the Netherlands; Department of Vascular Surgery, Erasmus MC, Rotterdam, the Netherlands; Department of Anesthesiology, Erasmus MC, Rotterdam, the Netherlands
| | - Sanne E Hoeks
- Department of Anesthesiology, Erasmus MC, Rotterdam, the Netherlands
| | - Alida Kindt
- Metabolomics and Analytics Centre, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
| | - Lieke Lamont
- Metabolomics and Analytics Centre, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Adriaan Moelker
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Sander Ten Raa
- Department of Vascular Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Burhan Hussain
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands; Department of Radiology, Beatrix hospital, Gorinchem, the Netherlands
| | - José Oliveira-Pinto
- Department of Vascular Surgery, Erasmus MC, Rotterdam, the Netherlands; Department of Angiology and Vascular Surgery, Centro Hospitalar São João, Porto, Portugal; Department of Surgery and Physiology, Faculty of Medicine of Oporto, Porto, Portugal
| | - Arne S Ijpma
- Department of Pathology, Erasmus MC, Rotterdam, the Netherlands
| | - Felix van Lier
- Department of Anesthesiology, Erasmus MC, Rotterdam, the Netherlands
| | - K Martijn Akkerhuis
- Department of Cardiology, Thorax Centre, Cardiovascular Institute, Erasmus MC, Rotterdam, the Netherlands
| | | | - Thomas Hankemeier
- Metabolomics and Analytics Centre, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
| | - Yolanda de Rijke
- Department of Clinical Chemistry, Erasmus MC, Rotterdam, the Netherlands
| | - Hence Jm Verhagen
- Department of Vascular Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Eric Boersma
- Department of Cardiology, Thorax Centre, Cardiovascular Institute, Erasmus MC, Rotterdam, the Netherlands
| | - Isabella Kardys
- Department of Cardiology, Thorax Centre, Cardiovascular Institute, Erasmus MC, Rotterdam, the Netherlands.
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Orimoto Y, Ishibashi H, Arima T, Imaeda Y, Maruyama Y, Mitsuoka H, Kodama A. Long-Term Outcomes of Simple Endovascular Aneurysm Repair Based on the Initial Aortic Diameter. Ann Thorac Cardiovasc Surg 2024; 30:23-00098. [PMID: 37880083 PMCID: PMC10902653 DOI: 10.5761/atcs.oa.23-00098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/10/2023] [Indexed: 10/27/2023] Open
Abstract
PURPOSE We aimed to investigate the effects of initial abdominal aortic aneurysm (AAA) diameter on aneurysmal sac expansion/shrinkage, endoleaks, and reintervention postelective simple endovascular aneurysm repair (EVAR). METHODS Overall, 228 patients monitored for >1 year after EVAR were analyzed. Male and female participants with initial AAA diameters <55 mm and <50 mm, respectively, composed the small group (group S), while those with initial AAA diameters ≥55 mm (men) and ≥50 mm (women) composed the large group (group L). Aneurysmal sac expansion of 10 mm and/or reintervention during follow-up (composite event) and its related factors were evaluated. RESULTS The 5-year freedom from composite event rate was significantly higher in group S (92.4 ± 2.8%) than that in group L (79.1 ± 4.9%; P <0.01). Multivariate analysis revealed AAA diameters before EVAR in group S (hazard ratio, 0.38; 95% confidence interval, 0.18-0.81; P = 0.01) and type II endoleak (T2EL) at discharge (hazard ratio, 2.83; 95% confidence interval, 1.29-6.20; P <0.01) as factors associated with the composite event. The freedom from composite event rate decreased to 51 ± 13% at 5 years in group L with T2EL. CONCLUSIONS Group S had high freedom from composite event rate; in group L, the rate decreased to 51% at 5 years with T2EL at discharge.
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Affiliation(s)
- Yuki Orimoto
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hiroyuki Ishibashi
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takahiro Arima
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Yusuke Imaeda
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Yuki Maruyama
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hiroki Mitsuoka
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Akio Kodama
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
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Lilja F, Wanhainen A, Mani K. Statin therapy after elective abdominal aortic aneurysm repair improves long-term survival. Br J Surg 2024; 111:znad383. [PMID: 38198155 PMCID: PMC10782213 DOI: 10.1093/bjs/znad383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/08/2023] [Accepted: 10/22/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Patients with abdominal aortic aneurysms are at high risk of cardiovascular events. Although statin therapy is indicated for most of these patients, no specific recommendation regarding the intensity of therapy exists. The aim of this study was to assess the possible effect of statin therapy on survival of patients undergoing abdominal aortic aneurysm repair and to investigate if high-intensity statin therapy was superior to low-moderate-intensity therapy. METHODS Data from nationwide Swedish registers on hospital admissions, operations, and medications for patients undergoing elective abdominal aortic aneurysm repair from 2006 to 2018 were collected. The effect of statin use was evaluated in three separate propensity score matched cohorts: perioperative mortality was analysed according to whether patients were on statins before abdominal aortic aneurysm repair or not; long-term survival was assessed according to whether patients were on statins during follow-up or not; and, for those on statins after surgery, long-term survival was analysed according to whether patients were on high-intensity or low-moderate-intensity statin therapy. RESULTS Preoperative statin use did not reduce 90-day perioperative mortality (OR 0.99, 95% c.i. 0.77 to 1.28), whilst there was a marked benefit regarding long-term survival for postoperative statin users (HR 1.43, 95% c.i. 1.34 to 1.54). High-intensity statin therapy had no advantage over low-medium-intensity statin therapy with regards to long-term survival (HR 1.00, 95% c.i. 0.80 to 1.25). CONCLUSION In this nationwide propensity score matched cohort study, preoperative statin treatment had no benefit regarding 90-day perioperative survival, but postoperative statin treatment markedly improved long-term survival. No additional benefit regarding high-dose statin treatment could be confirmed in this analysis.
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Affiliation(s)
- Fredrik Lilja
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Perioperative and Surgical Sciences, Umeå University, Umeå, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Guéroult AM, Bashir A, Azhar B, Budge J, Roy I, Loftus I, Holt P. Long Term Outcomes and Durability of Fenestrated Endovascular Aneurysm Repair: A Meta-analysis of Time to Event Data. Eur J Vasc Endovasc Surg 2024; 67:119-129. [PMID: 37572869 DOI: 10.1016/j.ejvs.2023.08.012] [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: 03/29/2023] [Revised: 07/13/2023] [Accepted: 08/07/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVE Despite widespread use, long term outcomes for fenestrated endovascular aneurysm repair (FEVAR) are uncertain. This meta-analysis reports long term survival, freedom from re-intervention, target vessel patency, and one year sac regression after FEVAR. DATA SOURCES Systematic review and meta-analysis to pool time to event data according to PRISMA guidelines. The study was registered with the international prospective register of systematic reviews (PROSPERO) (ID: CRD42023401468). REVIEW METHODS Medline, Embase, and Cochrane databases were searched from 1992 - 2023; articles were independently screened by two authors. Publication of complete time to event data for any outcome of interest was an inclusion criterion. Raw Kaplan-Meier probabilities were directly extracted from published curves and pooled by random effects. Risk of bias was assessed using ROBINS I and certainty with GRADE. RESULTS A total of 3 569 records were retrieved, 2 869 screened after duplicate removal, yielding 37 included studies (n = 4 371). The pooled mean age was 73.2 years (interquartile range [IQR] 72.2, 73.7) and 87.4% were male (95% confidence interval [CI] 85.8 - 88.9). Pooled Kaplan-Meier estimated probabilities of survival (n = 34 studies, n = 4 192 patients) at one, three, and five years were 91.6% (95% CI 90.2 - 92.9), 80.8% (95% CI 78.0 - 83.2), and 65.1% (95% CI 60.9 - 69.1). For freedom from re-intervention (n = 24, n = 3 211 patients) at one, three, and five years these were 90.2% (95% CI 87.3 - 92.7), 80.9% (95% CI 76.5 - 84.9), and 73.8% (95% CI 67.1 - 79.6). For target vessel patency (n = 13, n = 5805 target vessels) at one, three, and five years, these were 96.6% (95% CI 94.9 - 98.0), 94.5% (95% CI 91.7 - 96.7), and 93.1% (95% CI 89.3 - 96.0). Pooled estimate of sac regression (n = 8, n = 560) at one year was 40.2% (95% CI 28.9 - 52.7). Risk of bias was judged as moderate in 11 studies and low for the remaining 26. CONCLUSION There are moderate to low certainty data supporting reasonable long term outcome estimates following fenestrated endovascular aneurysm repair. Beyond five years there is a lack of data in the literature.
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Affiliation(s)
| | - Aisha Bashir
- St George's Vascular Institute; St George's, University of London, UK
| | - Bilal Azhar
- St George's Vascular Institute; St George's, University of London, UK
| | - James Budge
- St George's Vascular Institute; St George's, University of London, UK
| | - Iain Roy
- St George's Vascular Institute; St George's, University of London, UK
| | - Ian Loftus
- St George's Vascular Institute; St George's, University of London, UK
| | - Peter Holt
- St George's Vascular Institute; St George's, University of London, UK
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Kouvelos G, Volakakis G, Dakis K, Spanos K, Giannoukas A. The Role of Aortic Volume in the Natural History of Abdominal Aortic Aneurysms and Post-Endovascular Aortic Aneurysm Repair Surveillance. J Clin Med 2023; 13:193. [PMID: 38202200 PMCID: PMC10779888 DOI: 10.3390/jcm13010193] [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: 11/18/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
There has been a debate about whether maximum diameter can be solely used to assess the natural history of abdominal aortic aneurysm. The aim of the present review is to collect all the available evidence on the role of abdominal aortic aneurysm (AAA) volume in the natural history of AAAs, including small untreated AAAs and AAAs treated by EVAR. The current literature appears to reinforce the role of volume as a supplementary measure for evaluating the natural history of AAA, in both intact AAAs and after EVAR. The clinical impact of AAA volume measurements remains unclear. Several studies show that volumetric analysis can assess changes in AAAs and predict successful endoluminal exclusion after EVAR more accurately than diameter. However, most studies lack strict standardized measurement criteria and well-defined outcome definitions. It remains unclear whether volumetry could replace diameter assessment in defining the risk of rupture of AAAs and identifying clinically relevant sac growth.
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Affiliation(s)
- George Kouvelos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece; (G.V.); (K.D.); (K.S.); (A.G.)
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Asirwatham M, Konanki V, Lucas SJ, Grundy S, Zwiebel B, Shames M, Arnaoutakis DJ. Comparative outcomes of physician-modified fenestrated/branched endovascular aortic aneurysm repair in the setting of prior failed endovascular aneurysm repair. J Vasc Surg 2023; 78:1153-1161. [PMID: 37451371 DOI: 10.1016/j.jvs.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 06/29/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Endovascular treatment of aortic aneurysms involving renal-mesenteric arteries, especially in the setting of prior failed endovascular aneurysm repair (EVAR) typically requires fenestrated/branched endovascular aneurysm repair (F/BEVAR) with a custom-made device (CMD). CMDs are limited to select centers, and physician-modified endografts are an alternative treatment platform. Currently, there is no data on the outcomes of physician-modified F/BEVAR (PM-F/BEVAR) in the setting of failed prior EVAR. The purpose of this study was to evaluate the use of PM-F/BEVAR in patients with prior failed EVAR. METHODS A prospective database of consecutive patients treated at a single center with PM-F/BEVAR between March 2021 and November 2022 was retrospectively reviewed. The cohort was stratified by presence of a failed EVAR (type Ia endoleak or aneurysm development proximal to a prior EVAR) prior to PM-F/BEVAR. Demographics, operative details, and postoperative complications were compared between the groups using univariate analysis. One-year survival and freedom from reintervention were compared using the Kaplan-Meier method. RESULTS A total of 103 patients underwent PM-F/BEVAR during the study period; 27 (26%) were in the setting of prior EVAR. Patients with prior failed EVAR had similar age (75.2 ± 7.7 vs 71.5 ± 8.8 years; P = .058), male gender (n = 24 ; 89% vs n = 57 ; 75%; P = .130), and comorbid conditions except higher incidence of moderate-to-severe chronic obstructive pulmonary disease (n = 7 ; 26% vs n = 7 ; 9%; P = .047). Overall, aneurysm diameter was 65.5 ± 13.9 mm with aneurysms categorized as juxta-/pararenal in 43% and thoracoabdominal in 57%, with no differences between the groups. Twelve patients (14%) presented with symptomatic/ruptured aneurysms. The average number of target arteries incorporated per patient was 3.8. Four different aortic devices were modified with a greater proportion of Terumo TREO devices used in the failed EVAR group (P = .03). There was no difference in procedure time, radiation dose, or iodinated contrast use between groups. Overall technical success was 99%. Rates of 30-day mortality (n = 0 ; 0% vs n = 3 ; 4%; P = .565) and major adverse events (n = 6 ; 22% vs n = 16 ; 21%; P = 1.0) were similar between groups. For the overall cohort, rates of type 1 or 3 endoleak, branch vessel stenosis/occlusion, and reintervention were 2%, 1%, and 8%, respectively, with no difference between groups. One-year survival (failed EVAR 94% vs no EVAR 82%; P = .756) was similar between groups. CONCLUSIONS PM-F/BEVAR is a safe and effective treatment for patients with aneurysms involving the renal-mesenteric arteries in the setting of prior failed EVAR where additional technical challenges may be present. Additional follow-up is warranted to demonstrate long-term efficacy, but early results are encouraging and similar to those using CMDs.
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Affiliation(s)
- Mark Asirwatham
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Varun Konanki
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Spencer J Lucas
- Department of Surgery, University of South Dakota, Sioux Falls, SD
| | - Shane Grundy
- Department of Radiology, Tampa General Hospital, Tampa, FL
| | - Bruce Zwiebel
- Department of Radiology, Tampa General Hospital, Tampa, FL
| | - Murray Shames
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Dean J Arnaoutakis
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL.
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Haulon S, Steinmetz E, Feugier P, Magnan PE, Maurel B, Fabre D, Geng B, Doyle M, Twesigye I, Sobocinski J. Two-Year Results on Real-World Fenestrated or Branched Endovascular Repair for Complex Aortic Abdominal Aneurysm in France. J Endovasc Ther 2023:15266028231208653. [PMID: 37902436 DOI: 10.1177/15266028231208653] [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: 10/31/2023]
Abstract
PURPOSE To describe and compare mid-term outcomes from 2 real-world data collection efforts on fenestrated and branched endovascular aortic repair (fbEVAR) for complex abdominal aortic aneurysms (AAAs) in France and to evaluate the potential of health care databases for long-term post-market surveillance (PMS) and continued reimbursement approval. METHODS Two real-world studies were conducted in France: a retrospective health care database study (SNDS) and a prospective clinical study. In the SNDS study, data from implantation and/or hospital stays occurring during follow-up were extracted for all patients treated with the study devices from April 2012 to December 2018. In the clinical study, high-risk patients undergoing fbEVAR with the study devices were enrolled consecutively at 15 sites in France from December 2016 to November 2018. RESULTS Data from 1073 patients were extracted from SNDS and compared with analogous variables from 186 patients in the clinical study. Most demographic details were similar between studies (SNDS vs clinical: mean age, 71.9 vs 71.8 years; men, 91.0% vs 89.8%), as was 30-day mortality (SNDS: 5.5%, clinical: 4.3%). Patients received custom-made fenestrated or branched devices (SNDS: 80.7%, clinical: 96.2%) or CE-marked Zenith Fenestrated devices (SNDS: 19.3%, clinical: 3.8%). Initial or technical success was above 94% for both studies. Two-year freedom from all-cause mortality was 80.0% (SNDS) and 85.1% (clinical study). Two-year freedom from aneurysm-related mortality was 93.8% (SNDS) and 94.6% (clinical study). Detailed imaging outcomes were not captured within SNDS; however, information on secondary procedures to restore patency was available and used as a surrogate measure for secondary interventions. Two-year freedom from secondary interventions was 73% for the SNDS study. In the clinical study, at 2 years, aneurysm stability or shrinkage was observed in 92.3% of patients, freedom from target vessel primary patency loss was above 95% for all visceral target vessels, and freedom from secondary interventions was 79.1%. CONCLUSION Real-world outcomes from the SNDS and clinical study suggest positive mid-term outcomes in high-risk populations following fbEVAR for complex AAAs. The similarities between these studies suggest that the use of health care databases may be an alternative to prospective clinical studies for long-term follow-up and PMS. CLINICAL IMPACT Positive results following endovascular repair of complex abdominal aortic aneurysms are observed from data extracted from both the French health care database and a post-market clinical study despite initial high-risk patient status and diverse center experience. These outcomes parallel more rigorously designed studies and suggest that with careful study design, real-world data collections have high translatable value to add to the clinical understanding of fenestrated and branched endovascular aortic repair (fbEVAR).
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Affiliation(s)
- Stéphan Haulon
- Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France
| | | | | | | | | | - Dominique Fabre
- Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Paris, France
| | - Bo Geng
- Cook Research Incorporated, West Lafayette, IN, USA
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Bouwens E, Vanmaele A, Hoeks SE, Verhagen HJM, Fioole B, Moelker A, ten Raa S, Hussain B, Oliveira-Pinto J, Bastos Gonçalves F, Ijpma AS, Hoefer IE, van Lier F, Akkerhuis KM, Majoor-Krakauer DF, Boersma E, Kardys I. Circulating biomarkers of cardiovascular disease are related to aneurysm volume in abdominal aortic aneurysm. Vasc Med 2023; 28:433-442. [PMID: 37395286 PMCID: PMC10559648 DOI: 10.1177/1358863x231181159] [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] [Indexed: 07/04/2023]
Abstract
BACKGROUND Surveillance programs in abdominal aortic aneurysms (AAA) are mainly based on imaging and leave room for improvement to timely identify patients at risk for AAA growth. Many biomarkers are dysregulated in patients with AAA, which fuels interest in biomarkers as indicators of disease progression. We examined associations of 92 cardiovascular disease (CVD)-related circulating biomarkers with AAA and sac volume. METHODS In a cross-sectional analysis, we separately investigated (1) 110 watchful waiting (WW) patients (undergoing periodic surveillance imaging without planned intervention) and (2) 203 patients after endovascular aneurysm repair (EVAR). The Cardiovascular Panel III (Olink Proteomics AB, Sweden) was used to measure 92 CVD-related circulating biomarkers. We used cluster analyses to investigate protein-based subphenotypes, and linear regression to examine associations of biomarkers with AAA and sac volume on CT scans. RESULTS Cluster analyses revealed two biomarker-based subgroups in both WW and EVAR patients, with higher levels of 76 and 74 proteins, respectively, in one subgroup versus the other. In WW patients, uPA showed a borderline significant association with AAA volume. Adjusting for clinical characteristics, there was a difference of -0.092 (-0.148, -0.036) loge mL in AAA volume per SD uPA. In EVAR patients, after multivariable adjustment, four biomarkers remained significantly associated with sac volume. The mean effects on sac volume per SD difference were: LDLR: -0.128 (-0.212, -0.044), TFPI: 0.139 (0.049, 0.229), TIMP4: 0.110 (0.023, 0.197), IGFBP-2: 0.103 (0.012, 0.194). CONCLUSION LDLR, TFPI, TIMP4, and IGFBP-2 were independently associated with sac volume after EVAR. Subgroups of patients with high levels of the majority of CVD-related biomarkers emphasize the intertwined relationship between AAA and CVD.ClinicalTrials.gov Identifier: NCT03703947.
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Affiliation(s)
- Elke Bouwens
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
- Department of Vascular Surgery, Erasmus MC, Rotterdam, The Netherlands
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - Alexander Vanmaele
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
- Department of Vascular Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Sanne E Hoeks
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - Hence JM Verhagen
- Department of Vascular Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Adriaan Moelker
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Sander ten Raa
- Department of Vascular Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Burhan Hussain
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
- Department of Radiology, Beatrix Hospital, Gorinchem, The Netherlands
| | - José Oliveira-Pinto
- Department of Vascular Surgery, Erasmus MC, Rotterdam, The Netherlands
- Department of Angiology and Vascular Surgery, Centro Hospitalar São João, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine of Oporto, Porto, Portugal
| | - Frederico Bastos Gonçalves
- Department of Vascular Surgery, Erasmus MC, Rotterdam, The Netherlands
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Arne S Ijpma
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
| | - Imo E Hoefer
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Felix van Lier
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Eric Boersma
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | - Isabella Kardys
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
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Torabi N, Shafiee A, Heidari A, Hajizeinali M, Jalali A, Hajizeinali A. Predictors of Five-Year Survival after EVAR: 10-Year Experience of Single-Center Cohort Study. Ann Vasc Surg 2023; 96:115-124. [PMID: 37068627 DOI: 10.1016/j.avsg.2023.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Endovascular abdominal aortic repair (EVAR) is the main therapeutic option for repairing abdominal aortic aneurysms (AAAs). We aimed to determine the long-term outcomes of patients who underwent EVAR at our center. METHODS In this retrospective cohort study, patients who underwent EVAR for intact isolated AAA at Tehran Heart Center between 2007 and 2017 were included. Clinical outcomes and the frequency of mortality were analyzed for follow-up periods. We calculated the 5-year survival rate and its predictors for our patients using Kaplan-Meier estimation. RESULTS We included the data of all patients (154 patients, mean age = 70.7 [± 8.0] years, 96.1% men) who successfully underwent EVAR at our center. The most common risk factors were coronary artery disease (70.1%), hypertension (68.2%), smoking (64.9%), and dyslipidemia (39.6%). There was no mortality during the procedure. The median follow-up was 65.5 months. An average decrease of 9.07 mm (95% confidence interval: 6.9-11.2) occurred in the size of the AAA. During follow-up, 12 patients developed some complications, 49 died, and 7 did not complete the follow-up. The 5-year survival rate was 75% (3.9%). The independent predictors for 5-year survival were age (hazard ratio [HR] = 1.06, P = 0.002) and anemia (HR = 1.91, P = 0.029). Despite not being statistically significant, dyslipidemia (HR = 0.573, P = 0.078) and long intensive care unit/cardiac care unit stays (HR = 1.08, P = 0.070) were borderline mortality predictors. CONCLUSIONS This study depicted an acceptable survival rate for patients who underwent EVAR at our center. Age and anemia, 2 modifiable predictors of 5-year survival, can probably prolong the survival rate of patients, which requires evaluation later.
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Affiliation(s)
- Nasim Torabi
- Department of Cardiology, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Akbar Shafiee
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Department of Cardiovascular Research, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Heidari
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Mohammadmohsen Hajizeinali
- Department of Cardiovascular Research, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Department of Cardiovascular Research, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Alimohammad Hajizeinali
- Interventional Cardiology Department, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
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Rašiová M, Koščo M, Moščovič M, Pavlíková V, Habalová V, Židzik J, Tormová Z, Hudák M, Bavoľárová M, Perečinský S, Dekanová L, Tkáč I. Factors associated with all-cause mortality following endovascular abdominal aortic aneurysm repair. VASA 2023; 52:325-331. [PMID: 37350324 DOI: 10.1024/0301-1526/a001081] [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: 06/24/2023]
Abstract
Background: Knowledge of factors that influence all-cause mortality after endovascular abdominal aortic aneurysm repair (EVAR) could improve therapeutic strategies post-EVAR and thus patient prognosis. Our study aimed to evaluate the association between sociodemographic information, comorbidities, laboratory parameters, treatment, selected anatomical and genetic factors and all-cause mortality post-EVAR. Patients and methods: We reviewed all patients who had undergone elective EVAR for non-ruptured abdominal aortic aneurysm (AAA) between January 2010 and December 2019. AAA size (maximum diameter and volume) was measured using CT-angiography. Sac expansion was defined as at least 5 mm increase, sac regression as at least 5 mm decrease in the sac diameter determined at 36±3 months post-EVAR in relation to pre-EVAR AAA diameter. Adjustments were performed for age, hypertension, diabetes mellitus, dyslipidaemia, sex, smoking, number of lumbar arteries, patency of inferior mesenteric artery and number of reinterventions post-EVAR. Results: One hundred and sixty-two patients (150 men, 12 women) with a mean age of 72.6±7.3 years were included in the analysis. Pre-EVAR AAA diameter (HR 1.07; 95% CI 1.03 - 1.12; p=0.001), pre-EVAR AAA volume (HR 1.01; 95% CI 1.002 - 1.011; p=0.008), post-EVAR sac diameter (HR 1.06; 95% CI 1.03 - 1.10; p=0.000), post-EVAR sac volume (HR 1.01; 95% CI 1.002 - 1.011; p=0.006) and anticoagulation therapy (HR 2.46; 95% CI 1.18 - 5.14; p=0.019) were associated with higher mortality in multivariate analysis. Sac regression (HR 0.42; 95% CI 0.22 - 0.82; p=0.011), and treatment with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) (HR 0.71; 95% CI 0.36 - 0.97; p=0.047) were associated with lower mortality. Conclusions: Greater pre- and post-EVAR diameter and volume, failure of sac regression and anticoagulation were associated with higher mortality post-EVAR. Reduced mortality was observed in patients treated with ACE inhibitors or ARBs, and in patients with AAA sac regression.
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Affiliation(s)
- Mária Rašiová
- Department of Angiology, Faculty of Medicine, East Slovak Institute of Cardiovascular Diseases, University of Pavol Jozef Šafárik, Košice, Slovakia
| | - Martin Koščo
- Department of Angiology, Faculty of Medicine, East Slovak Institute of Cardiovascular Diseases, University of Pavol Jozef Šafárik, Košice, Slovakia
| | - Matej Moščovič
- Department of Angiology, Faculty of Medicine, East Slovak Institute of Cardiovascular Diseases, University of Pavol Jozef Šafárik, Košice, Slovakia
| | - Veronika Pavlíková
- Department of Angiology, Faculty of Medicine, East Slovak Institute of Cardiovascular Diseases, University of Pavol Jozef Šafárik, Košice, Slovakia
| | - Viera Habalová
- Department of Medicine Biology, Faculty of Medicine, University of Pavol Jozef Šafárik, Košice, Slovakia
| | - Jozef Židzik
- Department of Medicine Biology, Faculty of Medicine, University of Pavol Jozef Šafárik, Košice, Slovakia
| | - Zuzana Tormová
- Department of Angiology, Faculty of Medicine, East Slovak Institute of Cardiovascular Diseases, University of Pavol Jozef Šafárik, Košice, Slovakia
| | - Marek Hudák
- Department of Angiology, Faculty of Medicine, East Slovak Institute of Cardiovascular Diseases, University of Pavol Jozef Šafárik, Košice, Slovakia
| | - Marta Bavoľárová
- Department of Cardiology, Štefan Kukura Hospital, Michalovce, Slovakia
| | - Slavomír Perečinský
- Department of Occupational Medicine and Clinical Toxicology, Faculty of Medicine, University of Pavol Jozef Šafárik, Košice, Slovakia
| | - Lucia Dekanová
- Department of Angiology, Faculty of Medicine, East Slovak Institute of Cardiovascular Diseases, University of Pavol Jozef Šafárik, Košice, Slovakia
| | - Ivan Tkáč
- Department of Internal Medicine 4, Faculty of Medicine, University of Pavol Jozef Šafárik, Košice, Slovakia
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Kano M, Nishibe T, Iwahashi T, Maekawa K, Nakano Y, Matsumoto R, Fujiyoshi T, Ogino H, Kato N, Dardik A. Association of simple renal cysts to aneurysm sac shrinkage in true thoracic aortic aneurysms after thoracic endovascular aortic repair. J Vasc Surg 2023; 78:624-632. [PMID: 37116594 DOI: 10.1016/j.jvs.2023.02.031] [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: 01/10/2023] [Revised: 02/20/2023] [Accepted: 02/23/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND An increased prevalence of thoracic aortic aneurysms (TAA) has been demonstrated in patients with simple renal cysts (SRC); patients with SRC have a less elastic aortic wall than those without SRC. The purpose of this study was to evaluate aneurysm sac shrinkage after thoracic endovascular aortic repair (TEVAR) for true TAA in patients with and without SRC. METHODS One hundred three patients with true aneurysms of the thoracic aorta who underwent TEVAR at our university hospital from November 2013 to December 2021 were included in this study. Aneurysm sac size was compared between that on baseline preoperative computed tomography and that on postoperative computed tomography scans at 1 year. A change in aneurysm sac size ≥5 mm was considered to be significant, whether due to expansion or shrinkage. RESULTS The patients were divided into two groups: those with SRC (46 patients [45%]) and those without SRC (57 patients [55%]). At 1 year, there was a significant difference in the proportion of aneurysm sac shrinkage between patients with SRC and those without SRC (23.9% vs 59.6%; P < .001). Patients with SRC showed significantly less aneurysm sac shrinkage than those without SRC (-1.8 ± 5.6 mm vs -5.1 ± 6.6 mm; P = .009). Univariable and multivariable analyses showed that the initial sac diameter (odds ratio, 1.08; 95% confidence interval, 1.03-1.14; P = .002) and the presence of SRC (odds ratio, 0.15; 95% confidence interval, 0.06-0.40; P < .001) were positively and negatively associated with aneurysm sac shrinkage after TEVAR, respectively. CONCLUSIONS The presence of a SRC was independently associated with failure of aneurysm sac shrinkage after TEVAR for true TAA. This suggests that the presence of a SRC may be a predictor for the failure of aneurysm sac shrinkage after TEVAR.
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Affiliation(s)
- Masaki Kano
- Department of Cardiovascular Surgery, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan.
| | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan; Faculty of Medical Informatics, Hokkaido Information University, Ebetsu, Hokkaido, Japan
| | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Koki Maekawa
- Department of Cardiovascular Surgery, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Yu Nakano
- Department of Cardiovascular Surgery, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Ryumon Matsumoto
- Department of Cardiovascular Surgery, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Toshiki Fujiyoshi
- Department of Cardiovascular Surgery, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Nobuhiko Kato
- Faculty of Medical Informatics, Hokkaido Information University, Ebetsu, Hokkaido, Japan
| | - Alan Dardik
- Department of Surgery, Yale University School of Medicine, New Haven, CT
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Holden A, Hill AA, Khashram M, Heyligers JM, Wiersema AM, Hayes PD, Reijnen MM. Active aortic aneurysm sac treatment with shape memory polymer during endovascular aneurysm repair. J Vasc Surg Cases Innov Tech 2023; 9:101241. [PMID: 37496654 PMCID: PMC10366578 DOI: 10.1016/j.jvscit.2023.101241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/24/2023] [Indexed: 07/28/2023] Open
Abstract
Preprocedural image analysis and intraprocedural techniques to fully treat infrarenal abdominal aortic aneurysm sacs outside of the endograft with shape memory polymer (SMP) devices during endovascular aneurysm repair were developed. Prospective, multicenter, single-arm studies were performed. SMP is a porous, self-expanding polyurethane polymer material. Target lumen volumes (aortic flow lumen volume minus endograft volume) were estimated from the preprocedural imaging studies and endograft dimensions. SMP was delivered immediately after endograft deployment via a 6F sheath jailed in a bowed position in the sac. Technical success was achieved in all cases, defined as implanting enough fully expanded SMP volume to treat the actual target lumen volume.
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Affiliation(s)
- Andrew Holden
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Andrew A. Hill
- Vascular Services, Auckland City Hospital, Auckland, New Zealand
| | - Manar Khashram
- Department of Vascular and Endovascular Surgery, Waikato Hospital Hamilton, Hamilton, New Zealand
| | - Jan M.M. Heyligers
- Department of Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Arno M. Wiersema
- Department of Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands
| | - Paul D. Hayes
- St. John's Innovation Centre, Cambridge, United Kingdom
| | - Michel M.P.J. Reijnen
- Department of Surgery, Rijnstate, Arnhem, The Netherlands
- Multi-Modality Medical Imaging Group, University of Twente, Enschede, The Netherlands
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Nocun W, Muscogliati R, Al-Tawil M, Jubouri M, Alsmadi AS, Surkhi AO, Bailey DM, Williams IM, Bashir M. Impact of patient demographics and intraoperative characteristics on abdominal aortic aneurysm sac following endovascular repair. Asian Cardiovasc Thorac Ann 2023; 31:633-643. [PMID: 37264635 DOI: 10.1177/02184923231178704] [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: 06/03/2023]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) has become the preferred treatment for abdominal aortic aneurysm (AAA). Its main aim is to seal the perfusion of the aneurysmal sac and, thus, induce sac regression and subsequent aortic remodelling. Aneurysmal sac regression has been linked to the short- and long-term clinical outcomes post-EVAR. It has also been shown to be influenced by endograft device choice, with several of these available commercially. This review summarises and discusses current evidence on the influence of pre- and intraoperative factors on sac regression. Additionally, this review aims to highlight the device-specific variations in sac regression to provide an overall holistic approach to treating AAAs with EVAR. METHODS A comprehensive literature search was conducted using multiple electronic databases to identify and extract relevant data. RESULTS Female sex, >70 mm original sac diameters, higher pre-procedural fibrinogen levels, smoking and low intra-aneurysmal pressure were found to positively impact sac regression. Whereas renal impairment, ischemic heart disease, high intra-aneurysmal pressure and aneurysm neck thrombus negatively influenced sac regression. Patent lumbar arteries, age, statins and hypercholesterolaemia displayed conflicting evidence regarding sac regression. Regarding the EVAR endografts compared, newer generation devices such as the Anaconda mainly showed the most optimal results. CONCLUSION Sac regression following EVAR in AAA is an important prognostic factor for morbidity and mortality. Nevertheless, several pre- and intraoperative factors can have an influence on sac regression. Therefore, it is necessary to take them into account when assessing AAA patients for EVAR to optimise outcomes. The choice of EVAR stent-graft can also affect sac regression, with evidence suggesting that the Fenestrated Anaconda is associated with the most favourable results.
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Affiliation(s)
- Weronika Nocun
- School of Medicine, University of Nottingham, Nottingham, UK
| | | | | | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Ayah S Alsmadi
- Faculty of Medicine, Jordan University of Science & Technology, Irbid, Jordan
| | | | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales, Cardiff, UK
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Jubouri M, Surkhi AO, Tan SZ, Bailey DM, Williams IM, Bashir M. Correlative effect between sac regression and patient longevity following endovascular solution for abdominal aortic aneurysms: an international analysis. Asian Cardiovasc Thorac Ann 2023; 31:557-564. [PMID: 36168205 DOI: 10.1177/02184923221129983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Since the introduction of endovascular aortic repair (EVAR) it has become the mainstay treatment for abdominal aortic aneurysms. Several EVAR devices exist commercially, yet, the Terumo Aortic Fenestrated Anaconda™ endograft has demonstrated outstanding results. Evidence in the literature suggests that sac regression could be linked to patient survival and longevity. The main scope of this study is to evaluate sac regression and survival achieved using the Fenestrated Anaconda™ endograft and to discuss relevant literature. MATERIALS AND METHODS The current study represents a nine-year cross-sectional international analysis of custom-made Fenestrated Anaconda™ device. For the statistical analysis, SPSS 28 for Windows and R were utilised. Pearson chi-square analysis was used to assess differences in cumulative distribution frequencies between select variables. Statistical significance for all two-tailed tests was set at p < 0.05. RESULTS A total of 5,058 patients received the Fenestrated Anaconda™ in this study, either due to unsuitable/complex anatomy for competitor devices (n = 3,891) or based on surgeon preference (n = 1,167). A sac regression of 0-30% was observed in 4,772 (94.3%) over the first four years post-EVAR. Here, 99.6% of patients receiving the Fenestrated Anaconda™ due to unsuitable/complex anatomy for competitor devices and 76.8% based on surgeon preference had 0-30% sac regression. During years 5-9 of follow-up, all patients had 20-45% sac regression. Patient survival during the first six years post-EVAR was 100% but dropped to 77.1% in years 7-9. Survival differed between categorical patient subsets based on the indication. DISCUSSION The Fenestrated Anaconda™ has been proven to be a highly effective EVAR endograft. Evidence in the literature clearly demonstrates that sac regression is an accurate prognostic factor for patient survival and longevity.
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Affiliation(s)
- Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | | | - Sven Zcp Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Wales, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Wales, UK
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales (HEIW), Cardiff, UK
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Pasqui E, de Donato G, Molino C, Abu Leil M, Anzaldi MG, Galzerano G, Palasciano G. Residual Aneurysmal Sac Shrinkage Post-Endovascular Aneurysm Repair: The Role of Preoperative Inflammatory Markers. Biomedicines 2023; 11:1920. [PMID: 37509562 PMCID: PMC10377044 DOI: 10.3390/biomedicines11071920] [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: 05/29/2023] [Revised: 06/30/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION In this study, we evaluated the role of preoperative inflammatory markers as Neutrophil-to-Lymphocyte (NLR) and Platelet-to-Lymphocyte (PLR) ratios in relation to post-endovascular aneurysm repair (EVAR) sac shrinkage, which is known to be an important factor for abdominal aortic aneurysm (AAA) healing. METHODS This was a single-center retrospective observational study. All patients who underwent the EVAR procedure from January 2017 to December 2020 were eligible for this study. Pre-operative blood samples of all patients admitted were used to calculate NLR and PLR. Sac shrinkage was defined as a decrease of ≥5 mm in the maximal sac diameter. The optimal NLR and PLR cut-offs for aneurysmal sac shrinkage were obtained from ROC curves. Stepwise multivariate analysis was performed in order to identify independent risk and protective factors for the absence of AAA shrinkage. Kaplan-Meier curves were used to evaluate survival rates with respect to the AAA shrinkage. RESULTS A total of 184 patients were finally enrolled. The mean age was 75.8 ± 8.3 years, and 85.9% were male (158/184). At a mean follow-up of 43 ± 18 months, sac shrinkage was registered in 107 patients (58.1%). No-shrinking AAA patients were more likely to be older, to have a higher level of NLR and PLR, and be an active smoker. Kaplan-Meier curves highlighted a higher rate of survival for shrinking AAA patients with respect to their counterparts (p < 0.03). Multivariate analysis outlined active smoking and NLR as independent risk factors for no-shrinking AAA. CONCLUSIONS Inflammation emerged as a possible causative factor for no-shrinking AAA, playing a role in aneurysmal sac remodeling. This study revealed that inflammatory biomarkers, such as NLR and PLR, can be used as a preoperative index of AAA sac behavior after EVAR procedures.
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Affiliation(s)
- Edoardo Pasqui
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Gianmarco de Donato
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Cecilia Molino
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Mustafa Abu Leil
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Manfredi Giuseppe Anzaldi
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Giuseppe Galzerano
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Giancarlo Palasciano
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
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Li C, de Guerre LEVM, Dansey K, Lu J, Patel PB, Yao M, Malas MB, Jones DW, Schermerhorn ML. The impact of completion and follow-up endoleaks on survival, reintervention, and rupture. J Vasc Surg 2023; 77:1676-1684. [PMID: 36841312 PMCID: PMC10213115 DOI: 10.1016/j.jvs.2023.02.009] [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: 03/21/2021] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 02/27/2023]
Abstract
OBJECTIVE Endoleaks may be seen at case completion of endovascular abdominal aortic aneurysm repair (EVAR), and the presence of an endoleak may impact outcomes. However, the clinical implications of various endoleaks seen during follow-up is not well-described. Therefore, we studied the impact of endoleaks at completion and at follow-up on mid-term outcomes. METHODS We reviewed patients who underwent EVAR from 2003 to 2016 within the Vascular Quality Initiative-Medicare database and identified patients with endoleak at procedure completion and during follow-up, excluding those presenting with rupture. We stratified cohorts by presence of completion and follow-up endoleak subtypes. The primary outcome was 5-year survival, and secondary outcomes included 5-year freedom from reintervention and freedom from rupture. We used Kaplan-Meier estimates and log-rank tests to analyze differences in time-to-event endpoints. RESULTS Of 21,745 patients with completion endoleak data, 5085 (23%) had an endoleak. Compared with those without endoleak, those with type I endoleaks had lower 5-year survival (69% vs 75%; P < .001), type II endoleaks had higher survival (79%; P < .001), and types III, IV, and indeterminate were not statistically different (73%, 73%, and 75%, respectively). Freedom from reintervention for types I and III endoleaks were significantly lower than no endoleak cohort (I: 76%; P < .001; III: 72%; P < .001 vs 83%), but freedom from rupture was higher for those with type II and III endoleak (95% and 97% vs 94%; P < .001). Of 14,479 patients with detailed follow-up endoleak data, 2290 (16%) had an endoleak. Compared with those without endoleak, types I and III had significantly lower 5-year survival (I: 80%; P = .002; III: 66%; P < .001 vs 84%), but there were no differences for types II (82%) and indeterminate (77%). Those with any type of follow-up endoleak had lower 5-year freedom from reintervention (I: 70%; P < .001; II: 76%; P = .006; III: 36%; P < .001; indeterminate: 60%; P = .007 vs 84%), and lower freedom from rupture (I: 92%; P < .001; II: 91%; P = .16; III: 88%; P = .01; indeterminate: 90%; P = .11 vs 94%). CONCLUSIONS Compared with patients with no endoleak, those with type I completion endoleaks have lower 5-year survival and freedom from reintervention. Patients with types I and III follow-up endoleaks also have lower survival, and any endoleak at follow-up is associated with lower freedom from reintervention and freedom from rupture. These data highlight the importance of careful patient selection and close postoperative follow-up after EVAR, as the presence of endoleaks, specifically type I and III, over time portends worse outcomes.
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Affiliation(s)
- Chun Li
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston MA, USA
| | - Livia E V M de Guerre
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston MA, USA
| | - Kirsten Dansey
- Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - Jinny Lu
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston MA, USA
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston MA, USA
| | - Mengdi Yao
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston MA, USA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego Health System, San Diego CA, USA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, University of Massachusetts, Worchester, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston MA, USA.
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Massmann A, Fries P, Shayesteh-Kheslat R, Buecker A, Berg P, Frenzel F. Feasibility of aortic aneurysm sac embolization using a novel shape memory polymer embolic device. Eur Radiol Exp 2023; 7:12. [PMID: 37009937 PMCID: PMC10068687 DOI: 10.1186/s41747-023-00328-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 01/30/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND We investigated the feasibility of aneurysm sac embolization using a novel self-expanding porous shape memory polymer (SMP) device during endovascular aortic abdominal or thoracic aneurysm repair (EVAR). METHODS Retrospective analysis of consecutive patients treated at 2 centers in Germany. Patients were treated from January 2019 to July 2021 with follow-up at 7 days and 3, 6, and 12 months. Aneurysm sacs were implanted with SMP devices immediately following endograft placement during the same procedure. Primary endpoint was technically successful SMP-device deployment into the aneurysm sac outside the endograft. Secondary endpoints were changes in aneurysm volume and associated complications (e.g., endoleaks). RESULTS We included 18 patients (16 males), aged 72 ± 9 years, achieving 100% technical success. Mean preprocedure aortic aneurysm sac volume was 195 ± 117 mL with a perfused aneurysm volume of 97 ± 60 mL. A mean of 24 ± 12 SMP devices per patient were used (range 5-45, corresponding to 6.25-56.25 mL expanded embolic material volume). All evaluable patients exhibited sac regression except 2 patients yet to reach 3-month follow-up. At mean 11 ± 7 months (range 3-24), change in aneurysm volume from baseline was -30 ± 21 mL (p < 0.001). In 8 patients, aneurysm regression was observed despite type 2 endoleaks in 6 and type 1A endoleaks in 2, none of them requiring further intervention to date. No morbidity or mortality related to this treatment occurred. CONCLUSIONS SMP devices for aortic aneurysm sac embolization during endovascular repair appear feasible and safe in this small case series. Prospective studies are needed. KEY POINTS • Shape memory polymer is a novel, self-expanding, porous, and radiolucent embolic device material. • Aortic aneurysm sacs were treated with polymer devices immediately following endograft placement. • Aortic aneurysm sac regression was observed in all patients with over 3-month follow-up. • Aortic aneurysm sac regression was observed even in the presence of endoleaks.
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Affiliation(s)
- Alexander Massmann
- Radiology and Nuclear Medicine, Bosch Health Campus, Robert-Bosch-Krankenhaus, Auerbachstraße 110, 70376, Stuttgart, Germany.
| | - Peter Fries
- Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Roushanak Shayesteh-Kheslat
- Clinic for General, Visceral, Vascular and Pediatric Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Arno Buecker
- Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Patrick Berg
- Clinic for Vascular Surgery, Katholisches Karl-Leisner-Klinikum, Kevelaer, Germany
| | - Felix Frenzel
- Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
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Kontopodis N, Galanakis N, Kiparakis M, Ioannou CV, Kakisis I, Geroulakos G, Antoniou GA. Pre-Emptive Embolization of the Aneurysm Sac or Aortic Side Branches in Endovascular Aneurysm Repair: Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials. Ann Vasc Surg 2023; 91:90-107. [PMID: 36494004 DOI: 10.1016/j.avsg.2022.10.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 10/04/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND To investigate outcomes of pre-emptive embolization of the aneurysm sac or aortic side branches in endovascular aneurysm repair (EVAR). METHODS The review was reported as per Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 with a preregistered protocol. Bibliographic sources (MEDLINE, Embase, and CENTRAL) were searched using subject headings and free text terms. Randomized controlled trials comparing EVAR with versus without embolization were included. Pooled estimates of dichotomous outcomes were calculated using odds ratio (OR) or risk difference (RD) and 95% confidence interval (CI) applying the Mantel-Haenszel method. Continuous outcomes were summarized using mean difference (MD) and 95% CI applying the inverse variance method. The certainty of evidence was appraised with the Grading of Recommendations Assessment, Development, and Evaluation framework. Version 2 of the Cochrane tool was used to assess the risk of bias. Trial sequential analysis assumed alpha = 5% and power = 80%. RESULTS Four randomized controlled trials were included. No significant difference was found in aneurysm-related mortality (RD 0.00, 95% CI -0.03 to 0.03), overall mortality (OR 1.85, 95% CI 0.42-8.13), aneurysm rupture (RD 0.00, 95% CI -0.03 to 0.03), type II endoleak-related reintervention (RD -0.07, 95% CI -0.21 to 0.06), procedure time (MD 20.12, 95% CI -11.54 to 51.77), or fluoroscopy time (MD 11.17, 95% CI -11.22 to 33.56). Patients with pre-emptive embolization had significantly lower odds of type II endoleak (OR 0.45, 95% CI 0.26-0.78) and sac expansion (OR 0.19, 95% CI 0.07-0.52). The risk of bias was high for all outcomes. The certainty of evidence was very low for all outcomes, except for type II endoleak, for which it was low. Trial sequential analysis showed an inconclusive result for overall mortality and type II endoleak-related reintervention but confirmed the advantage of embolization in reducing type II endoleak and sac expansion. CONCLUSIONS Limited, low certainty data suggest pre-emptive embolization confers no clinical benefits in EVAR.
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Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University General Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Greece
| | - Nikolaos Galanakis
- Interventional Radiology Unit, Department of Medical Imaging, University of Crete Medical School, Heraklion, Greece
| | - Michalis Kiparakis
- Cardiac Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University General Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Greece
| | - Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University General Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Greece
| | - Ioannis Kakisis
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK; Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.
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Summers SP, Rastogi V, Yadavalli SD, Wang SX, Schaller MS, Jones DW, Ochoa Chaar CI, de Bruin JL, Verhagen HJM, Schermerhorn ML. The Association between Diabetes Mellitus and its Management with Outcomes following Endovascular Repair for Descending Thoracic Aortic Aneurysm. J Vasc Surg 2023:S0741-5214(23)00545-1. [PMID: 36966848 DOI: 10.1016/j.jvs.2023.02.024] [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: 12/30/2022] [Revised: 02/17/2023] [Accepted: 02/24/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE Prior literature is conflicted regarding the effect of diabetes mellitus (DM) on outcomes following endovascular repair of aortic aneurysms. In this study, we aimed to examine the association between DM and outcomes following TEVAR for TAA. METHODS We identified patients who underwent TEVAR for TAA of the descending thoracic aorta in the VQI between 2014-2022. We created two cohorts, DM and non-DM, based on the patient's preoperative DM status, and secondarily sub-stratified DM patients by management strategy: dietary management, non-insulin medications, and insulin therapy cohorts. Outcomes included perioperative and 5-year mortality, in-hospital complications, indications for repair, and one-year sac dynamics, which were analyzed with multivariable cox regression, multivariable logistic regression, and chi-square tests, respectively. RESULTS We identified 2,637 patients, of which 473 (18%) had DM preoperatively. Among DM patients, 25% were diet controlled, 54% non-insulin medications, and 21% insulin therapy. Within patients who underwent TEVAR for TAA, the proportions of ruptured presentation were higher in the dietary (11.1%) and insulin (14.3%) managed cohorts relative to non-insulin therapy (6.6%) and non-DM (6.9%). Following multivariable regression analysis, we found that DM was associated with similar perioperative mortality (OR: 1.14 [95% CI: 0.70-1.81]) and 5-year mortality compared with non-DM patients (HR: 1.15 [95% CI: 0.91-1.48]). Furthermore, all in-hospital complications were comparable between DM patients and non-DM patients. Compared with non-DM patients, dietary management of DM was significantly associated with higher adjusted perioperative mortality (OR: 2.16 [95% CI: 1.03-4.19]) and higher 5-year mortality (HR: 1.50 [95% CI: 1.03-2.20]), though this was not the case for other DM subgroups. All cohorts displayed similar one-year sac dynamics, with sac regression occurring in 47% of non-DM patients vs 46% of DM patients (P= 0.27). CONCLUSION Preoperatively, DM patients that underwent TEVAR had a higher proportion of ruptured presentation when treated with diet or insulin medications than when treated with non-insulin medications. Following TEVAR for descending TAA, DM was associated with a similar risk of perioperative and 5-year mortality to non-DM. In contrast, dietary therapy for DM was associated with significantly higher perioperative mortality and 5-year mortality.
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Affiliation(s)
- Steven P Summers
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sophie X Wang
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Melinda S Schaller
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Cassius I Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - 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
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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50
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Bruijn LE, Louhichi J, Veger HTC, Wever JJ, van Dijk LC, van Overhagen H, Hamming JF, Statius van Eps RGS. Identifying Patients at High Risk for Post-EVAR Aneurysm Sac Growth. J Endovasc Ther 2023:15266028231158302. [PMID: 36927207 DOI: 10.1177/15266028231158302] [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: 03/18/2023]
Abstract
PURPOSE Post-EVAR (endovascular aneurysm repair) aneurysm sac growth can be seen as therapy failure as it is a risk factor for post-EVAR aneurysm rupture. This study sought to identify preoperative patient predictors for developing post-EVAR aneurysm sac growth. MATERIAL AND METHODS A systematic review was conducted to select potential predictive preoperative factors for post-EVAR sac growth (including a total of 34.886 patients), which were evaluated by a retrospective single-center analysis of patients undergoing EVAR between 2009 and 2019 (N=247) with pre-EVAR computed tomography scans and at least 1 year follow-up. The primary study outcome was post-EVAR abdominal aortic aneurysm (AAA) sac enlargement (≥5 mm diameter increase). Multivariate Cox regression and Kaplan-Meier survival curves were constructed. RESULTS Potential correlative factors for post-EVAR sac growth included in the cohort analysis were age, sex, anticoagulants, antiplatelets, renal insufficiency, anemia, low thrombocyte count, pulmonary comorbidities, aneurysm diameter, neck diameter, neck angle, neck length, configuration of intraluminal thrombus, common iliac artery diameter, the number of patent lumbar arteries, and a patent inferior mesenteric artery. Multivariate analysis showed that infrarenal neck angulation (hazard ratio, 1.014; confidence interval (CI), 1.001-1.026; p=0.034) and the number of patent lumbar arteries (hazard ratio, 1.340; CI, 1.131-1.588; p<0.001) were associated with post-EVAR growth. Difference in estimated freedom from post-EVAR sac growth for patients with ≥4 patent lumbar arteries versus <4 patent lumbar arteries became clear after 2 years: 88.5% versus 100%, respectively (p<0.001). Of note, 31% of the patients (n=51) with ≥4 patent lumbar arteries (n=167) developed post-EVAR sac growth. In our cohort, the median maximum AAA diameter was 57 mm (interquartile range [IQR] = 54-62) and the median postoperative follow-up time was 54 months (IQR = 34-79). In all, 23% (n=57) of the patients suffered from post-EVAR growth. The median time for post-EVAR growth was 37 months (IQR = 24-63). In 46 of the 57 post-EVAR growth cases (81%), an endoleak was observed; 2.4% (n=6) of the patients suffered from post-EVAR rupture. The total mortality in the cohort was 24% (n=60); 4% (n=10) was AAA related. CONCLUSIONS This study showed that having 4 or more patent lumbar arteries is an important predictive factor for postoperative sac growth in patients undergoing EVAR. CLINICAL IMPACT This study strongly suggests that having 4 or more patent lumbar arteries should be included in preoperative counseling for EVAR, in conjunction to the instructions for use (IFU).
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Affiliation(s)
- Laura E Bruijn
- Division of Vascular Surgery, Department of Surgery, Haga Teaching Hospital, The Hague, The Netherlands.,Division of Vascular Surgery, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jihene Louhichi
- Division of Vascular Surgery, Department of Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Hugo T C Veger
- Division of Vascular Surgery, Department of Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Jan J Wever
- Division of Vascular Surgery, Department of Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Lukas C van Dijk
- Division of Interventional Radiology, Department of Radiology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Hendrik van Overhagen
- Division of Interventional Radiology, Department of Radiology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Jaap F Hamming
- Division of Vascular Surgery, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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