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Becker D, Riggi M, Wyss TR, Jungi S, Weiss S, Kotelis D, Schmidli J, Bosiers MJ, Makaloski V. Indication and Outcome of Late Open Conversion after Abdominal Endovascular Aortic Repair. Ann Vasc Surg 2024; 106:196-204. [PMID: 38810725 DOI: 10.1016/j.avsg.2024.02.028] [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: 10/11/2023] [Revised: 02/20/2024] [Accepted: 02/24/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) has become the standard of care for patients with infrarenal aortic aneurysms over the last 2 decades. Endograft technology and treatment of complications like endoleaks, graft migration, or graft occlusion developed over time. However, sometimes open surgical conversion maybe required. Our aim was to analyze the indications, the technical aspects and outcomes in patients who underwent open conversion after EVAR with different types and generations of endografts. METHODS This retrospective single-center study reviewed all patients who underwent EVAR from 2004 to 2020. Open surgical conversions >1 month post EVAR were identified. Conversions for graft infection were excluded. Indications for conversion and operative technique were analyzed. Primary endpoint of the study was 30-day mortality. Secondary endpoints were re-interventions and follow-up mortality. RESULTS During 2004 and 2020, 443 consecutive EVARs were performed, and 28 patients required open surgical conversion, with an additional 3 referred from other hospitals (N = 31). The median age was 75 (range 58-93); 94% were male. Conversion was performed after a median time of 55 months (range 16-209). Twenty patients underwent elective and 11 emergency conversion. Indications for open conversion were graft migration, respectively, disease progression with endoleak type Ia and/or Ib in 52% (16/31) and sac expansion due to endoleak type II in 26% (8/31). Of the 31 patients, 17 (55%) had at least one previous endovascular re-intervention. All patients met the device-specific instructions for use for each implanted endograft. In-hospital intervention rate was 16% (5/31). Thirty-day mortality rate was 3% (1/31) with one patient died due to multiorgan failure after rupture with complete endograft replacement. Five patients (16%) died during follow-up. Mid-term follow-up was 47.5 months (range 24-203) with estimated cumulative survival rates of 97%, 89%, and 84%, at 1, 3, and 5 years, respectively. CONCLUSIONS Late open conversion remains a valuable treatment option and can be performed safely in elective and emergency setting with a low early mortality. Lifelong surveillance and prompt intervention when necessary are essential in ensuring optimal outcomes after EVAR and preventing the need for emergent conversions.
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Affiliation(s)
- Daniel Becker
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Manuela Riggi
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Rudolf Wyss
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Interventional Radiology and Vascular Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Silvan Jungi
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Salome Weiss
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drosos Kotelis
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürg Schmidli
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michel Joseph Bosiers
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Li R, Sidawy A, Nguyen BN. Acute Intraoperative Conversion from Endovascular to Open vs Planned Open Operation for Abdominal Aortic Aneurysm: A Propensity-Score Matched Study from the American College of Surgeons NSQIP-Targeted Database. J Am Coll Surg 2024; 239:162-170. [PMID: 38372301 DOI: 10.1097/xcs.0000000000001050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
BACKGROUND Evaluating outcomes for acute intraoperative conversion to open surgery during endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) was difficult due to low incidence. This study aimed to compare 30-day outcomes between patients with acute intraoperative conversion during EVAR and planned open surgery, and to identify risk factors associated with acute conversion. STUDY DESIGN Patients who underwent EVAR or planned open AAA repair were identified in American College of Surgeons NSQIP-targeted databases from 2012 to 2021. Patients with acute intraoperative conversion during EVAR were selected. A 1:3 propensity-score matching was used to match demographics, baseline characteristics, surgical indications, aneurysm size and extent, and emergency cases between the conversion open and planned open groups. Thirty-day postoperative outcomes were assessed. RESULTS Of 20,566 EVAR cases, 177 (0.86%) had acute intraoperative conversion to open surgery. The conversion open group was matched to 504 of 5,249 planned open patients. Conversion open and planned open groups had comparable 30-day mortality (23.43% vs 17.46%, p = 0.09) and organ system complications, including major adverse cardiovascular event (14.86% vs 10.71%, p = 0.17), pulmonary complications (17.71% vs 24.01%, p = 0.09), and renal complications (8.57% vs 11.11%, p = 0.39). The conversion open group had lower bleeding requiring transfusion (48.57% vs 75.60%, p < 0.01), shorter operation time (p < 0.01), and shorter length of stay (p < 0.01). Other postoperative outcomes did not differ. Risk factors associated with acute intraoperative conversion included ruptured aneurysm with or without hypotension. Protective factors included hypertension and aortic distal aneurysm extent. CONCLUSIONS Although this study does not endorse a universal "EVAR first" strategy for all patients with AAA, EVAR can be attempted first in eligible patients with AAA. Even when EVAR is unsuccessful, intraoperative conversion to open surgery still appears to be safe compared with planned open repair.
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Affiliation(s)
- Renxi Li
- From The George Washington University School of Medicine and Health Sciences, Washington, DC (Li)
| | - Anton Sidawy
- Department of Surgery, The George Washington University Hospital, Washington, DC (Sidawy, Nguyen)
| | - Bao-Ngoc Nguyen
- Department of Surgery, The George Washington University Hospital, Washington, DC (Sidawy, Nguyen)
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Kim HK, Park PJ, Park JH, Oh YJ, Jung CW, Jun H. Nationwide analysis of EVAR explantation outcomes in Korea: A comprehensive dataset study. Vascular 2024:17085381241265159. [PMID: 39037289 DOI: 10.1177/17085381241265159] [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: 07/23/2024]
Abstract
OBJECTIVE Endovascular aortic aneurysm repair (EVAR) is the primary treatment for abdominal aortic aneurysms, constituting 70%-80% of interventions. Despite initial benefits, long-term studies show increased mortality. Using nationwide data, this study assesses outcomes of EVAR, open aortic repair (OAR), and EVAR explantation (EE) in Korea, while exploring characteristics of late open conversion, including the rising EE incidence. METHODS Employing the National Health Insurance Service database, covering health-related data for nearly 50 million Koreans, the study spanned from 2002 to 2020. Patients with AAA diagnoses (I71.3 or I71.4) were categorized into OAR, EVAR, and EE groups based on procedural codes. Statistical analyses, including t-tests, Fisher's exact tests, Cox proportional hazard models, and multivariate Cox regression, assessed baseline characteristics, mortality risks, and factors within the EE group. RESULTS The analysis encompassed 26,195 patients, with 66.19% in the EVAR group, 31.87% in the OAR group, and 1.94% in the EE group. EVAR cases steadily increased from 2002 to 2018. Survival rates favored EVAR, followed by OAR and EE. 30-day survival was lower in EE than EVAR. Multivariate analysis for EE revealed no risk factors for 30-days survival but identified age, chronic kidney disease, high Charlson Comorbidity Index scores, and less than 6 months since EVAR as risk factors for overall mortality. CONCLUSION Rising EE trends with increased EVAR adoption, particularly evident in the Korean dataset, underscore inferior outcomes. This highlights the critical need for strategic initial treatment decisions and timely interventions to enhance overall results and mitigate the unfavorable EE incidence.
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Affiliation(s)
- Hyo Kee Kim
- Department of Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Pyoung Jae Park
- Department of Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Jee Hyun Park
- Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Young Ju Oh
- Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Cheol Woong Jung
- Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Heungman Jun
- Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
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Esposito D, Onida S, Turner B, Rawashdeh M, Jenkins MP, Pulli R, Davies AH. Systematic review and meta-analysis of outcomes after semi-conversion with graft preservation for failed endovascular aneurysm repair. J Vasc Surg 2024; 79:973-981.e4. [PMID: 37619915 DOI: 10.1016/j.jvs.2023.08.113] [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: 06/05/2023] [Revised: 07/24/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the outcomes after semi-conversion (open conversion with graft preservation) after failed endovascular aneurysm repair (EVAR). The primary outcomes were 30-day mortality and semi-conversion failure. Secondary outcomes were 30-day major systemic complications, endoleak recurrence, reinterventions, and overall survival. METHODS The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol was prospectively registered on PROSPERO (CRD42023421153). All studies reporting the outcomes of semi-conversions for failed EVAR were eligible for inclusion. Quality assessment was performed using the Methodological Index for Non-Randomized Studies (MINORS) tool. A random effects meta-regression of proportions was conducted using the double arcsine-Tukey transformation, given the frequent zero event rate in the primary outcome. Heterogeneity was assessed with the I2 statistic. RESULTS Eight studies were included in the review after full text screening. A total of 196 patients underwent semi-conversion at a mean time from EVAR of 47.4 months, 68.9% in an elective setting. Mean age at conversion was 78.1 years, and the main indication was isolated endoleak type II (70.1% of cases). Aortic clamping was not necessary in 92.3% of semi-conversions; the aortic sac was opened in 96.1% of cases; in 93.3% of cases, ligation/suture of one or more culprit arteries were performed; and aortic neck banding was executed in 29.2%. At 30 days from surgery, the pooled mortality and the major systemic complications rates were 5.3% (I2 = 24.9%) and 13.4% (I2 = 54.3%), respectively. At follow-up, endoleak recurred after 12.6% semi-conversions (I2 = 83.2%), and the rate of reinterventions was 7% (I2 = 50.1%); the semi-conversion failure rate was 5.5% (I2 = 54.1%), and the overall survival was 84.6% (I2 = 33.3%). CONCLUSIONS Semi-conversions have acceptable 30-day mortality rates, but the early and mid-term risks of complications, reinterventions, ruptures, and infections are not negligible. This procedure might be an alternative to complete or partial graft explant in patients whom aortic cross-clamping is not ideal.
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Affiliation(s)
- Davide Esposito
- Department of Cardiothoracic and Vascular Surgery, Careggi University Hospital, Florence, Italy; Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
| | - Sarah Onida
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Benedict Turner
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Majd Rawashdeh
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Michael P Jenkins
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Raffaele Pulli
- Department of Cardiothoracic and Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Alun H Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Esposito D, Rawashdeh M, Onida S, Turner B, Machin M, Pulli R, Davies AH. Systematic Review and Meta-Analysis of Elective Open Conversion versus Fenestrated and Branched Endovascular Repair for Previous Non-Infected Failed Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2024; 67:393-405. [PMID: 37748552 DOI: 10.1016/j.ejvs.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: 06/01/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE To evaluate outcomes of patients electively undergoing fenestrated and branched endovascular repair (F/B-EVAR) or open conversion for failed previous non-infected endovascular aneurysm repair (EVAR). DATA SOURCES Embase, MEDLINE, Cochrane Library. REVIEW METHOD The protocol was prospectively registered on PROSPERO (CRD42023404091). The review followed the PRISMA guidelines; certainty was assessed through the GRADE and quality through MINORS tools. Outcomes data were pooled separately for F/B-EVAR and open conversion. A random effects meta-analysis of proportions was conducted; heterogeneity was assessed with the I2 statistic. RESULTS Thirty eight studies were included, for a total of 1 645 patients of whom 1 001 (60.9%) underwent an open conversion and 644 (39.1%) a F/B-EVAR. The quality of evidence was generally limited. GRADE certainty was judged low for 30 day death (in both groups) and F/B-EVAR technical success, and very low for the other outcomes. Pooled 30 day death was 2.3% (I2 33%) in the open conversion group and 2.4% (I2 0%) in the F/B-EVAR conversion group (p = .36). Technical success for F/B-EVAR was 94.1% (I2 23%). The pooled 30 day major systemic complications rate was higher in the open conversion (21.3%; I2 74%) than in the F/B-EVAR (15.7%; I2 78%) group (p = .52). At 18 months follow up, the pooled re-intervention rate was 4.5% (I2 58%) in the open conversion and 26% (I2 0%) in the F/B-EVAR group (p < .001), and overall survival was 92.5% (I2 59%) and 81.6% (I2 68%), respectively (p = .005). CONCLUSION In the elective setting, and excluding infections, the early results of both open conversion and F/B-EVAR after failed EVAR appear satisfactory. Although open conversion presented with higher complication rates in the first 30 days after surgery, at follow up it seemed to be associated with fewer re-interventions and better survival compared with F/B-EVAR.
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Affiliation(s)
- Davide Esposito
- Department of Cardiothoracic and Vascular Surgery, Careggi University Hospital, Florence, Italy; Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Majd Rawashdeh
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sarah Onida
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Benedict Turner
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Matthew Machin
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Raffaele Pulli
- Department of Cardiothoracic and Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Alun H Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Lopez-Espada C, Linares-Palomino J, Guerra Requena M, Serrano Hernando FJ, Iborra Ortega E, Fernández-Samos R, Zanabili Al-Sibbai A, González Cañas E, Rodriguez Sánchez JM, Zaragozá García JM, García León A, Manzano Grossi S, de Benito L, Gil Sala D, Revuelta Mariño L. Multicenter Comparative Analysis of Late Open Conversion in Patients With Adherence and Nonadherence to Instructions for Use Endovascular Aneurysm Repair. J Endovasc Ther 2023; 30:867-876. [PMID: 35735201 DOI: 10.1177/15266028221102658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The widespread adoption of endovascular aneurysm repair (EVAR) as preferred treatment modality for abdominal aortic aneurysm (AAA) has enlarged the number of patients needing open surgical conversion (OSC). The relationship between adherence to Instructions For Use (IFU) and EVAR long-term outcomes remains controversial. The aim of this study is to compare preoperative differences and postoperative outcomes between EVAR patients not adjusted to IFU and adjusted to IFU who underwent OSC. METHODS This multicenter retrospective study reviewed 33 explanted EVARs between January 2003 and December 2019 at 14 Vascular Units. Patients were included if OSC occurred >30 days after implantation and excluded if explantation was performed to treat an endograft infection, aortic dissection, or traumatic transections. Variables analyzed included baseline characteristics, adherence to IFU, implant and explant procedural details, secondary reinterventions, and postoperative outcomes. RESULTS Fifteen explanted patients (15/33, 45.5%) were identified not accomplished to IFU (out-IFU) at initial EVAR vs 18 explanted patients adjusted (in-IFU). During follow-up, a mean of 1.73±1.2 secondary reinterventions were performed, with more type I endoleaks treated in the subgroup out-IFU: 16.7% vs 6.3% in-IFU patients and more type III endoleaks (8.3% vs 0%). Patients out-IFU had shorter mean interval from implant to explant: 47.60±28.8 months vs 71.17±48. Type II endoleak was the most frequent indication for explantation. Low-flow endoleaks (types II, IV, V) account for 44% of indications for OSC in subgroup of patients in-IFU, compared with 13.3% in patients out-IFU and high-flow endoleaks (types I and III) were the main indication for patients out-IFU (33.3% vs 16.7% in-IFU). Total endograft explantation was performed in 57.5% of cases (19/33) and more suprarenal clamping was required in the subgroup out-IFU. Overall, 30-day mortality rate was 12.1% (4/33): 20% for patients out-IFU and 5.6% in-IFU. CONCLUSIONS In our experience, type II endoleak is the most common indication for conversion and differences have been found between patients treated outside IFU with explantation taking place earlier during follow-up, mainly due to high-flow endoleaks and with higher mortality in comparison with patients adjusted to IFU. Ongoing research is required to delve into these differences.
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Affiliation(s)
| | - Jose Linares-Palomino
- Vascular Surgery Unit, University Hospital Virgen de las Nieves, Granada, Spain
- Department of Surgery, University of Granada, Granada, Spain
| | | | | | | | | | | | - Elena González Cañas
- Vascular Surgery Unit, Corporació Sanitaria Parc Tauli de Sabadell, Sabadell, Spain
| | | | | | - Andrés García León
- Vascular Surgery Unit, University Hospital Virgen de Valme, Sevilla, Spain
| | | | - Luis de Benito
- Vascular Surgery Unit, University Hospital Fundación Alcorcón, Madrid, Spain
| | - Daniel Gil Sala
- Vascular Surgery Unit, Vall d'Hebron University Hospital, Barcelona, Spain
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Lopez Espada C, Behrendt CA, Mani K, D'Oria M, Lattman T, Khashram M, Altreuther M, Cohnert TU, Pherwani A, Budtz-Lilly J. Editor's Choice - The VASCUNExplanT Project: An International Study Assessing Open Surgical Conversion of Failed Non-Infected Endovascular Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2023; 66:653-660. [PMID: 37490979 DOI: 10.1016/j.ejvs.2023.07.029] [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: 02/23/2023] [Revised: 07/09/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE The need for open surgical conversion (OSC) after failed endovascular aortic aneurysm repair (EVAR) persists, despite expanding endovascular options for secondary intervention. The VASCUNExplanT project collected international data to identify risk factors for failed EVAR, as well as OSC outcomes. This retrospective cross sectional study analysed data after OSC for failed EVAR from the VASCUNET international collaboration. METHODS VASCUNET queried registries from its 28 member countries, and 17 collaborated with data from patients who underwent OSC (2005 - 2020). Any OSC for infection was excluded. Data included demographics, EVAR, and OSC procedural details, as well as post-operative mortality and complication rates. RESULTS There were 348 OSC patients from 17 centres, of whom 33 (9.4%) were women. There were 130 (37.4%) devices originally deployed outside of instructions for use. The most common indication for OSC was endoleak (n = 143, 41.1%); ruptures accounted for 17.2% of cases. The median time from EVAR to OSC was 48.6 months [IQR 29.7, 71.6]; median abdominal aortic aneurysm diameter at OSC was 70.5 mm [IQR 61, 82]. A total of 160 (45.6%) patients underwent one or more re-interventions prior to OSC, while 63 patients (18.1%) underwent more than one re-intervention (range 1 - 5). Overall, the 30 day mortality rate post-OSC was 11.8% (n = 41), 11.1% for men and 18.2% for women (p = .23). The 30 day mortality rate was 6.1% for elective cases, and 28.3% for ruptures (p < .0001). The predicted 90 day survival for the entire cohort was 88.3% (95% CI 84.3 - 91.3). Multivariable analysis revealed rupture (OR 4.23; 95% CI 2.05 - 8.75; p < .0001) and total graft explantation (OR 2.10; 95% CI 1.02 - 4.34; p = .04) as the only statistically significant predictive factors for 30 day death. CONCLUSION This multicentre analysis of patients who underwent OSC shows that, despite varying case mix and operative techniques, OSC is feasible but associated with significant morbidity and mortality rates, particularly when performed for rupture.
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Affiliation(s)
- Cristina Lopez Espada
- Vascular Surgery Unit, University Hospital Virgen de las Nieves, Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain.
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Thomas Lattman
- Kantonsspital Winterthur, Swissvasc Registry, Zurich, Switzerland
| | - Manar Khashram
- Waikato Hospital, University of Auckland, Auckland, New Zealand
| | - Martin Altreuther
- Department of Vascular Surgery, St Olavs Hospital, Trondheim, Norway
| | - Tina U Cohnert
- Department of Vascular Surgery, Graz Medical University, Graz, Austria
| | - Arun Pherwani
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Jacob Budtz-Lilly
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Aarhus University Hospital, Aarhus, Denmark
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Walensi M, Krasniuk I, Tsilimparis N, Hoffmann JN. [Late Open Semi-conversion with Endograft Preservation for (Type II) Endoleaks with Late Aneurysm Sac Enlargement after EVAR - Indications, Method and Results in Our Own Patient Collective]. Zentralbl Chir 2023; 148:445-453. [PMID: 37846164 DOI: 10.1055/a-2174-7563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
EVAR (endovascular aortic repair) is the most common method for treating an abdominal aortic aneurysm, but according to the latest findings it carries the risk of subsequent complications. These can be caused by (late) aneurysm sac growth. If conservative and surgical therapies fail to treat the aneurysm sac growth, open conversion is necessary to prevent aneurysm rupture. There are several options for open conversion, in which the EVAR prosthesis can be completely preserved or is (partially) removed. Late open semi-conversion with complete in-situ preservation of the EVAR-prosthesis and gathering of the aneurysm sac are a less invasive method than complete conversion and may be performed instead for selected patients. The aim of the present work is to present the surgical method, including indications and technical information, as well as the presentation of the results in our recent patient collective.All patients semi-converted in our department of vascular surgery and phlebology due to (type II) endoleak were included. All data are presented as n (%) or median (range).Between 6/2019 and 3/2023, 13 patients underwent semi-conversion 6 (2-12) years (median, range) after the initial EVAR. The aneurysm sac diameter at the time of semi-conversion was 69 mm (58-95 mm), the operating time was 114 min (97-147 min), the blood loss was 100 ml (100-1500 ml). Five (38%) patients received blood transfusion intraoperatively and 2 (15%) postoperatively. The stay in the intensive care unit lasted 1 (1-5) days, the hospitalisation time was 8 (6-11) days. Postoperative complications were intestinal atony (3 [23%], 1 [8%] with nausea/emesis and gastric tube insertion), anaemia (2 [15%]), hyponatraemia (2 [15%]), delirium (1 [8%]), COVID-19 infection (1 [8%]) and 1 [8%] intra-abdominal postoperative bleeding with the indication for surgical revision and the transfusion of 8 erythrocyte concentrates.Semi-conversion is a safe and practicable surgical method with few severe complications for a selected group of patients, which should be considered as an alternative to more invasive methods with (partial) removal of the EVAR-prosthesis. Further long-term studies comparing semi-conversion to full conversion are needed to demonstrate its benefits.
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Affiliation(s)
- Mikolaj Walensi
- Klinik für Gefäßchirurgie und Phlebologie, Contilia Gruppe, Elisabeth-Krankenhaus, Essen, Deutschland
| | - Iuri Krasniuk
- Klinik für Gefäßchirurgie und Phlebologie, Contilia Gruppe, Elisabeth-Krankenhaus, Essen, Deutschland
| | - Nikolaos Tsilimparis
- Abteilung für Gefäßchirurgie - Vaskuläre und Endovaskuläre Chirurgie, LMU Klinikum München, München, Deutschland
| | - Johannes N Hoffmann
- Klinik für Gefäßchirurgie und Phlebologie, Contilia Gruppe, Elisabeth-Krankenhaus, Essen, Deutschland
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10
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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11
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Sen I, Kanzafarova I, Yonkus J, Mendes BC, Colglazier JJ, Shuja F, DeMartino RR, Kalra M, Rasmussen TE. Clinical presentation, operative management, and long-term outcomes of rupture after previous abdominal aortic aneurysm repair. J Vasc Surg 2023; 77:396-405.e7. [PMID: 36272507 DOI: 10.1016/j.jvs.2022.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/30/2022] [Accepted: 08/08/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate the presentation trends, intervention, and survival of patients who had been treated for late abdominal aortic aneurysm rupture (LAR) after open repair (OR) or endovascular aortic aneurysm repair (EVAR). METHODS We reviewed the clinical data from a single-center, retrospective database for patients treated for LAR from 2000 to 2020. The end points were the 30-day mortality, major postoperative complication, and survival. The outcomes between LAR managed with EVAR (group I) vs OR were compared (group II). RESULTS Of 390 patients with infrarenal aortic rupture, 40 (10%) had experienced aortic rupture after prior aortic repair and comprised the LAR cohort (34 men; age 78 ± 8 years). LAR had occurred before EVAR in 30 and before OR in 10 patients. LAR was more common in the second half of the study with 32 patients after 2010. LAR after prior OR was secondary to ruptured para-anastomotic pseudoaneurysms. After initial EVAR, LAR had occurred despite reintervention in 17 patients (42%). The time to LAR was shorter after prior EVAR than after OR (6 ± 4 vs 12 ± 4 years, respectively; P = .003). Treatment for LAR was EVAR for 25 patients (63%; group I) and OR for 15 (37%, group II). LAR after initial OR was managed with endovascular salvage for 8 of 10 patients. Endovascular management was more frequent in the latter half of the study period. In group I, fenestrated repair had been used for seven patients (28%). Salvage for the remaining cases was feasible with EVAR, aortic cuffs, or limb extensions. The incidence of free rupture, time to treatment, 30-day mortality (8% vs 13%; P = .3), complications (32% vs 60%; P = .1), and disposition were similar between the two groups. Those in group I had had less blood loss (660 vs 3000 mL; P < .001) and less need for dialysis (0% vs 33%; P < .001) than those in group II. The median follow-up was 21 months (interquartile range, 6-45 months). The overall 1-, 3-, and 5-year survival was 76%, 52%, and 41%, respectively, and was similar between groups (28 vs 22 months; P = .48). Late mortality was not related to the aorta. CONCLUSIONS LAR after abdominal aortic aneurysm repair has been encountered more frequently in clinical practice, likely driven by the frequency of EVAR. However, most LARs, including those after previous OR, can now be salvaged with endovascular techniques with lower morbidity and mortality.
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Affiliation(s)
- Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
| | - Irina Kanzafarova
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jennifer Yonkus
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Todd E Rasmussen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
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12
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Onitsuka S, Ito H. Surgical Treatment of Sac Enlargement Due to Type II Endoleaks Following Endovascular Aneurysm Repair. Ann Vasc Dis 2023; 16:1-7. [PMID: 37006865 PMCID: PMC10064304 DOI: 10.3400/avd.ra.22-00115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/06/2022] [Indexed: 01/28/2023] Open
Abstract
An aneurysm sac enlargement caused by type II endoleak (T2EL) following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms may cause serious complications such as rupture. Consequently, methods that preoperatively prevent or postoperatively treat T2EL have been employed. When significant aneurysm enlargement occurs due to persistent T2EL, embolization is first performed through several access points. However, although these endovascular reinterventions have a high technical success rate and are safe, their effectiveness remains questionable. When such endovascular procedures fail to stabilize sac enlargement, open surgical conversion (OSC) becomes the last-resort treatment option. We review several strategies of OSC for the repair of T2EL following EVAR. Among the three main OSC procedures, namely, complete endograft removal, partial endograft removal, and complete endograft preservation, partial endograft removal under infrarenal clamping was considered the most appropriate owing to its less invasiveness and durability.
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Affiliation(s)
| | - Hiroyuki Ito
- Department of Vascular Surgery, Saiseikai Fukuoka General Hospital
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13
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Perini P, Gargiulo M, Silingardi R, Bonardelli S, Bellosta R, Franchin M, Michelagnoli S, Ferrari M, Turicchia GU, Freyrie A. Occult endoleaks revealed during open conversions after endovascular aortic aneurysm repair in a multicenter experience. INT ANGIOL 2022; 41:476-482. [PMID: 36121171 DOI: 10.23736/s0392-9590.22.04921-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND An occult endoleak (OE) may be the underlying cause of aneurysm sac expansion after endovascular aneurysm repair (EVAR). The aim of this study is to describe intraoperative findings of OE during surgical endograft explantations. METHODS This is a retrospective, multicenter analysis of all open conversions (OC) after EVAR from 1997 to 2020 in 12 vascular centers. We excluded patients with a preoperative diagnosis of endograft infection, endograft thrombosis, and thoracic-EVAR. An OE was defined as an endoleak revealed during OC not shown on preoperative imaging, which was likely the real cause for sac enlargement. We reported the number of OE, and we described the type of OE in relation to the initial alleged or associated endoleak. A separate analysis of patients with an initial diagnosis of endotension was also performed. RESULTS An OE was found in 32/255 patients (12.5%). In the 78.1% of the cases (25/32) a type II endoleak hid a type I or III endoleak. Endotension was the initial diagnosis of 26/255 patients (10.2%). In 4/26 cases (15.4%), a type I or II OE was revealed. In 5/26 cases (19.2%) an endograft infection was found intraoperatively. In 2/26 cases we found an angiosarcoma. Fifteen cases of endotension (57.7%) remained unexplained. CONCLUSIONS OE represent a not negligible cause of EVAR failure. A type II endoleak associated with sac enlargement may actually conceal a higher-flow endoleak. In most of the cases, the initial diagnosis of endotension remains unexplained. However, endotension sometimes conceals severe underlying pathologies such as infections.
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Affiliation(s)
- Paolo Perini
- Unit of Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy - .,Unit of Vascular Surgery, Cardio-Thoracic and Vascular Department, University Hospital of Parma, Parma, Italy -
| | - Mauro Gargiulo
- Unit of Vascular Surgery, Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Bologna, Italy
| | - Roberto Silingardi
- Unit of Vascular Surgery, Department of Biomedical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Bonardelli
- Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Raffaello Bellosta
- Vascular Surgery, Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Marco Franchin
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Stefano Michelagnoli
- Vascular and Endovascular Surgery, Department of Surgery, USL Toscana Centro, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Mauro Ferrari
- Vascular Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giorgio U Turicchia
- AUSL Romagna, Department of Vascular Surgery, Cesena Hospital, Forlì-Cesena, Italy
| | - Antonio Freyrie
- Unit of Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
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14
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Ibrahim M, Silver M, Jacob T, Meghpara M, Almadani M, Shiferson A, Rhee R, Pu Q. Open conversion after failed endovascular aneurysm repair is increasing and its 30-day mortality is higher than that after primary open repair. J Vasc Surg 2022; 76:1502-1510. [PMID: 35709860 DOI: 10.1016/j.jvs.2022.04.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/26/2022] [Accepted: 04/27/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) has become the preferred treatment of abdominal aortic aneurysms (AAAs). Recent studies have demonstrated that cases of EVAR failure repair and subsequent open conversion have increased. The aim of the present study was to evaluate the national trend of annual cases and assess the 30-day outcomes of conversion to open repair after failed EVAR compared with primary open repair. METHODS The National Surgical Quality Improvement Program database was queried for relevant Current Procedural Terminology and International Classification of Diseases, Ninth and Tenth Revision, codes to identify patients who had undergone conversion to open repair or primary open repair of nonruptured AAAs from 2009 to 2018. The annual trend of cases was assessed, and the perioperative outcomes of both procedures were compared. Multivariable logistic regression analyses were conducted to identify independent perioperative factors associated with mortality. RESULTS Of the 9635 patients with nonruptured AAAs included in the present analysis, 9250 had undergone primary repair and 385 had required open conversion. During the 10-year period, the annual number of cases of open conversion had steadily increased and that of primary repair had decreased. The incidence of postoperative complications was similar between both groups, except for cardiac arrest, which had occurred more frequently in the open conversion group. The 30-day mortality was higher in the open conversion group than in the primary group (9.6% vs 3.9%; P < .0001). Open conversion was also independently associated with higher odds of death (adjusted odds ratio [OR], 2.1; 95% confidence interval [CI], 1.8-2.4; P < .0001). When the average mortality in both groups was compared between the first and last 5 years, no difference was found (open conversion: 9.8% vs 9.5% [P = 1.00]; primary repair: 3.6% vs 4.2% [P = .19]). Other perioperative factors independently associated with mortality included increased age (OR, 1.8; 95% CI, 1.5-2.1; P < .0001), American Society of Anesthesiologists class ≥III (OR, 2.7; 95% CI, 1.1-6.6; P = .029), insulin-dependent diabetes (OR, 2.0; 95% CI, 1.2-3.3; P = .005), chronic obstructive pulmonary disease (OR, 1.4; 95% CI, 1.1-1.8; P = .006), the presence of dyspnea at rest (OR, 3.3; 95% CI, 1.8-6.1; P < .0001), and a high preoperative hematocrit (OR, 0.94; 95% CI, 0.93-0.97; P < .0001). CONCLUSIONS Open conversion to treat nonruptured AAAs after failed EVAR was independently associated with higher mortality. Also, the annual cases of open conversion have continued to increase without any significant changes in postoperative mortality. This highlights the danger of open conversion and stresses the need for better solutions to prevent and manage EVAR failure.
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Affiliation(s)
- Mudathir Ibrahim
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Michael Silver
- Division of Biostatistics, Maimonides Medical Center, Brooklyn, NY
| | - Theresa Jacob
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY; Clinical and Translational Research Laboratories, Maimonides Medical Center, Brooklyn, NY
| | - Melissa Meghpara
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Mahmoud Almadani
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | | | - Robert Rhee
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Qinghua Pu
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY.
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15
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Dié Loucou J, Salomon du Mont L, Jazayeri A, Mariet AS, Leboffe M, Blitti C, Delpy JP, Steinmetz E. Evaluation Of The Effectiveness Of Endovascular Treatment Of Type 2 Endoleaks. Ann Vasc Surg 2022:S0890-5096(22)00439-3. [PMID: 35878699 DOI: 10.1016/j.avsg.2022.06.099] [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: 05/04/2022] [Revised: 06/26/2022] [Accepted: 06/30/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Endovascular abdominal aortic aneurysm repair (EVAR) is a safe and minimally invasive alternative to open surgical repair for infra renal aortic aneuvrysm. EVAR requires lifelong post-procedural surveillance. Endoleaks represent the main complication. Type II endoleaks (EL2) are the most frequent and tend to be indolent. Most practitioners do not treat in EL2 as long as they are associated with stable aneurysm diameter. European guidelines recommend treatment in case of aneurysm growth. Several techniques can be offered, such as transarterial embolization and translumbar embolization. This study reports the experience and results of a single center for EL2 endovascular treatment. The aim of this study was to determine more precisely the efficacity of embolization for type 2 endoleaks treatment. MATERIAL AND METHODS A single center cohort of patients treated for EL2 with endovascular technique between 1998 and 2018 was formed to perform a descriptive analysis. Preoperative sizing, risk factors of endoleaks and intraoperative data were collected. CT scans were regularly performed after EVAR to detect endoleak recurrence. Clinical recurrence was defined as the persistence of aneurysm sac growth and radiological recurrence was defined as the occurrence of EL2 on a post-embolization CT scan. Data related to reintervention, overall mortality and aneurysm related mortality were also collected. Kaplan Meier survival analyses were used to determine the rates of reoperation-free survival and recurrence-free survival. RESULTS Six hundred seven patients underwent an endovascular treatment for abdominal aorta aneurysm between 1998 and 2018. One hundred forty-five type 2 endoleaks occurred during this period. Nineteen patients (median age 76 years), underwent endovascular treatment for EL2, with immediate success on 15 patients (8 transarterial embolization, 8 direct sac puncture and 3 combined procedures). During follow-up, 5 patients required a new translumbar embolization and 6 required an open surgery for recurrence of the EL2. Six patients died, 2 of them of causes related to the aneurysm. At 59,6 months median follow-up, 53% of the patients presented a radiologic recurrence, with a sac growth of more than 5 mm since last procedure in 4 patients (24%). CONCLUSION Long term clinical recurrence of type 2 endoleaks treated by endovascular procedures appear to be frequent in our experience, leading to several deaths and requiring open surgical treatment.
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Affiliation(s)
- J Dié Loucou
- Department of vascular surgery - University Hospital, Boulevard de Lattre de Tassigny 21000 Dijon, France
| | - L Salomon du Mont
- Department of vascular surgery - University Hospital, 3 Boulevard Alexandre Fleming, 25000 Besançon, France
| | - A Jazayeri
- Department of vascular surgery - University Hospital, Boulevard de Lattre de Tassigny 21000 Dijon, France
| | - A S Mariet
- Department of public health - University Hospital, Boulevard de Lattre de Tassigny 21000 Dijon, France
| | - M Leboffe
- Department of vascular surgery - University Hospital, Boulevard de Lattre de Tassigny 21000 Dijon, France
| | - C Blitti
- Department of vascular surgery - University Hospital, Boulevard de Lattre de Tassigny 21000 Dijon, France
| | - J P Delpy
- Department of vascular surgery - University Hospital, Boulevard de Lattre de Tassigny 21000 Dijon, France
| | - E Steinmetz
- Department of vascular surgery - University Hospital, Boulevard de Lattre de Tassigny 21000 Dijon, France
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16
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Xodo A, D’Oria M, Mendes B, Bertoglio L, Mani K, Gargiulo M, Budtz-Lilly J, Antonello M, Veraldi GF, Pilon F, Milite D, Calvagna C, Griselli F, Taglialavoro J, Bassini S, Wanhainen A, Lindstrom D, Gallitto E, Mezzetto L, Mastrorilli D, Lepidi S, DeMartino R. Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes. J Pers Med 2022; 12:jpm12071018. [PMID: 35887518 PMCID: PMC9317732 DOI: 10.3390/jpm12071018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/06/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient's quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.
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Affiliation(s)
- Andrea Xodo
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Mario D’Oria
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
- Correspondence: ; Tel.: +39-0403994645
| | - Bernardo Mendes
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” San Raffaele University, 58-20132 Milan, Italy;
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Mauro Gargiulo
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Jacob Budtz-Lilly
- Department of Cardiovascular Surgery, Division of Vascular Surgery, Aarhus University Hospital, 161-8200 Aarhus, Denmark;
| | - Michele Antonello
- Vascular and Endovascular Surgery, University Hospital of Padova, DSCTV-University of Padova, 35128 Padova, Italy;
| | - Gian Franco Veraldi
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Fabio Pilon
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Domenico Milite
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Cristiano Calvagna
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Filippo Griselli
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Jacopo Taglialavoro
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Silvia Bassini
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - David Lindstrom
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Enrico Gallitto
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Luca Mezzetto
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Davide Mastrorilli
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Sandro Lepidi
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Randall DeMartino
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
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MUSCATO P, FRANCHIN M, VELO S, CAVI R, GUZZETTI L, TOZZI M, PIFFARETTI G. Results of open conversion with full endograft explantation after failed EVAR. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.23736/s1824-4777.22.01539-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Perini P, Gargiulo M, Silingardi R, Bonardelli S, Bellosta R, Piffaretti G, Michelagnoli S, Tusini N, Capelli P, Turicchia GU, Freyrie A. Multicentre Comparison between Open Conversions and Semi-Conversions for Late Endoleaks after EVAR. J Vasc Surg 2022; 76:104-112. [PMID: 35085746 DOI: 10.1016/j.jvs.2022.01.023] [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: 09/28/2021] [Accepted: 01/07/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this study is to compare early and follow-up outcomes of late open conversions (LOC, with complete or partial endograft explantation) and semi-conversions (SC, with endograft preservation) after EVAR in a multicentre experience. MATERIALS AND METHODS All-LOC and SC performed from 1997 to 2020 in 11 vascular centres were compared. Endograft infections or thrombosis were excluded. Primary endpoints were early mortality, and long-term survival estimates. Secondary endpoints were differences in: postoperative complication rates, conversion-related complications during follow-up. RESULTS In the considered period, 347 patients underwent surgery for EVAR complications. Among these, 270 were operated on for endoleaks (222 LOC, 48 SC). The 2 groups were homogeneous in terms of ASA score (3.2±0.7 LOC, 3±0.5 SC; P=.128) and main endograft characteristics (suprarenal fixation, bifurcated/aorto-uni-iliac configuration). Mean age was 75±8 at LOC and 79±7 at SC (P=.009). Reasons for LOC were: 62.2% (138/222) type I endoleak, 21.6% (48/222) type II, 7.7% (17/222) type III, 8.5% (19/222) endotension. Indications for SC were: 64.6% (31/48) type II endoleak, 33.3% (16/48) type I, 2.1% (1/48) type III. Thirty-day mortality was 12.2% (27/222) in the LOC group, and 10.4% (5/48) in the SC group (P=.73). Postoperative complication rate was higher in the LOC group (45.5% vs. 29.2%, P=.04). The estimated survival rate after LOC was 80% at 1 year and 64% at 5 years; after SC 72% at 1 year and 37% at 5 years (log-rank P=.01). During the median follow-up of 21.5 months (inter-quartile range 2.4-61), an endoleak after SC was found in the 38.3% of the cases; sac growth was recorded in the 27.7% of SC patients. CONCLUSIONS SC have an early benefit over LOC in terms of reduced postoperative complications, but a significantly inferior mid-term survival. The high rates of persistent and/or recurrent endoleaks reduce SC durability.
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Affiliation(s)
- Paolo Perini
- Division of Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy; Division of Vascular Surgery, Cardio-Thoracic and Vascular Department, University Hospital of Parma, Parma, Italy.
| | - Mauro Gargiulo
- Division of Vascular Surgery, Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Bologna, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Bonardelli
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Raffaello Bellosta
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Gabriele Piffaretti
- Division of Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Stefano Michelagnoli
- Divison of Vascular and Endovascular Surgery, Department of Surgery, USL Toscana Centro, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Nicola Tusini
- Department of Vascular Surgery, AO Reggio Emilia, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - Patrizio Capelli
- Department of General and Vascular Surgery, AUSL Piacenza, Piacenza, Italy
| | | | - Antonio Freyrie
- Division of Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Open surgical conversion and management of patients with ruptured abdominal aortic aneurysm after previous endovascular aneurysm repair. SRP ARK CELOK LEK 2022. [DOI: 10.2298/sarh211229067m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction/Objective. The objective was to present the results and technical considerations from high-volume center when performing late open surgical conversion (LOSC) after endovascular aneurysm repair (EVAR) in ruptured abdominal aortic aneurysm (RAAA) patients. Methods. This was a single center retrospective study. LOSC was performed whenever eventual endovascular reintervention failed, was not feasible due to hostile anatomy and unavailability of specific endograft materials, or when patient was hemodynamically unstable necessitating emergent surgery. Results. All previously implanted EVARs had bimodular configuration with suprarenal fixation. Total endograft explantation was performed in 40% of patients. Hospital mortality was 20%. Both patients who died had total endograft explantation with supraceliac clamp lasting more than 30 minutes. 30-day mortality was 30%, with one more patient who died from pulmonary embolism after hospital discharge and two hospital deaths were due to myocardial infarction. Conclusion. LOSC due to RAAA after previous EVAR carries greater mortality for the patient, suggesting multifactorial impacts on the outcome. The appropriate choice of surgical method and technical success are of ultimate importance, with total graft explantation having negative impact on patient?s survival.
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Ketting S, Zoethout AC, Heyligers J, Wiersema AM, Yeung KK, Schurink GW, Verhagen HJ, de Vries JPP, Reijnen MM, Mees BM. Nationwide experience with EVAS relining of previous open or endovascular AAA treatment in the Netherlands. Ann Vasc Surg 2022; 84:250-264. [DOI: 10.1016/j.avsg.2021.12.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 12/20/2021] [Accepted: 12/30/2021] [Indexed: 11/16/2022]
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Kiernan A, Elsherif M, Fahey B, Canning C, Moloney T, Kavanagh E, O'Callaghan A, O'Neill S, Madhavan P, Martin Z. Rescue of Failed Aortic Repair with Fenestrated Endovascular Device. Ann Vasc Surg 2021; 82:265-275. [PMID: 34902472 DOI: 10.1016/j.avsg.2021.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/01/2021] [Accepted: 11/01/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The incidence of failed endovascular (EVAR) and open repair (OR) is increasing. Redo aortic repair is required in 10% of patients. Extension of the proximal sealing zone above the visceral arteries to adequate, healthier thoracic aorta using a fenestrated graft (FEVAR) can rescue a failing repair. A custom-made device can treat proximal type 1A endoleaks or proximal dilatation post endovascular or open repair, respectively. The aim of this investigation was to present a single-centre experience with FEVAR for patients with a failing aortic repair. METHODS A prospectively maintained database of FEVAR patients treated with a Zenithࣨ Fenestrated endovascular (ZFEN) device (Cook Medical LLC, Bloomington, Indiana, USA) was interrogated for individuals who had the device implanted as a rescue therapy after prior endovascular (EVAR) or open repair (OR). Statistical analysis was performed with SPSS v 25 software. RESULTS Between January 1, 2011 and March 31, 2019, 17 ZFEN devices were implanted. Ten patients had a type 1A endoleak from a prior EVAR and seven patients had proximal disease progression after prior OR. There were 12 males and 5 females, median age of 75 (interquartile range, IQR 7). 76.4% (n=13) of patients had an American Society of Anaesthesiologists (ASA) grade of 3. Primary technical success was 70.5% (n=12). Of the remainder, four cases (24%) had a type III endoleak at completion angiogram; of which, two patients (12%) required re-intervention within 30 days. One further case (6%) had primary assisted technical success as stenting of a flow limiting dissection flap in an iliac vessel was required. Peri-operative rate of deployment related complications and systemic complications were 5.8% (n=1) and 35% (n=6), respectively. Median length of hospital stay was 11 days (IQR 11). There was no mortality within the study follow up. Overall thirty-day re-intervention rate was 23.5%. Overall survival was 92% at one year. CONCLUSION FEVAR is a safe but technically challenging option for rescue of failing aortic repairs. These are a high risk group of patients and this is reflected in the high post-operative morbidity rate. Technical success was high and 30-day mortality was low.
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Affiliation(s)
- Aoife Kiernan
- St James's Vascular Institute, St James's Hospital, Dublin 8, Ireland
| | - Mohamed Elsherif
- St James's Vascular Institute, St James's Hospital, Dublin 8, Ireland
| | - Brian Fahey
- St James's Vascular Institute, St James's Hospital, Dublin 8, Ireland
| | - Caitríona Canning
- St James's Vascular Institute, St James's Hospital, Dublin 8, Ireland
| | - Tony Moloney
- Department of Vascular Surgery, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Eamon Kavanagh
- Department of Vascular Surgery, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | | | - Sean O'Neill
- St James's Vascular Institute, St James's Hospital, Dublin 8, Ireland
| | - Prakash Madhavan
- St James's Vascular Institute, St James's Hospital, Dublin 8, Ireland
| | - Zenia Martin
- St James's Vascular Institute, St James's Hospital, Dublin 8, Ireland
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22
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D'Oria M, Budtz-Lilly J, Lindstrom D, Lundberg G, Jonsson M, Wanhainen A, Mani K, Unosson J. Comparison of Early and Mid-Term Outcomes After Fenestrated-Branched Endovascular Aortic Repair in Patients With or Without Prior Infrarenal Repair. J Endovasc Ther 2021; 29:544-554. [PMID: 34781751 DOI: 10.1177/15266028211058686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The purpose of this study was to compare short- and mid-term outcomes of fenestrated-branched endovascular repair (F-BEVAR) of pararenal (PRAA)/thoracoabdominal (TAAA) aortic aneurysms in patients with or without prior endovascular/open (EVAR/OAR) infrarenal aortic repair. METHODS Data from consecutive F-BEVAR (2010-2019) at two high-volume aortic centers were retrospectively reviewed. Primary endpoints were technical success, 30-day mortality, and overall survival. Secondary endpoints included 30-day major adverse events (MAE), freedom from type I/III endoleaks, reinterventions, sac expansion, and target vessel (TV) primary patency. RESULTS A total of 222 consecutive patients were included for analysis; of these 58 (26.1%) had prior infrarenal repair (EVAR=33, OAR=25) and 164 (73.9%) had native PRAA/TAAA. At baseline, patients with prior infrarenal repair were older (mean age=75.1 vs 71.6 years, p=.005) and the proportion of females was lower (8.6% vs 29.3%, p=.002). Technical success was 97.8% (n=217) in the entire cohort, without any significant differences between study groups (94.8% vs 98.8%, p=.08). At 30 days, there were no significant differences between patients with prior infrarenal repair as compared with those without in rate of MAE (44.8% vs 54.9%, p=.59). The 5-year estimate of survival for those who underwent native aortic repair was 61.6%, versus 61.3% for those who had a previous repair (p=.67). The 5-year freedom from endoleaks I/III estimates were significantly lower in patients who had prior infrarenal repair as compared with patients undergoing treatment of native aneurysms (57.1% vs 66.1%, p=.03), mainly owing to TV-related endoleaks (ie, type IC and/or IIIC endoleaks). No significant differences were found between study groups in rates of reinterventions and TV primary patency. Five-year estimates of freedom from sac increase >5mm were significantly lower in patients who received F-BEVAR after previous infrarenal repair as compared with those who underwent treatment of native aneurysms (48.6% vs 77.5%, p=.002). CONCLUSIONS F-BEVAR is equally safe and feasible for treatment of patients with prior infrarenal repair as compared with those undergoing treatment for native aneurysms. Increased rates of TV-related endoleaks were observed which could lead to lower freedom from aneurysm sac shrinkage during follow-up. Nevertheless, the 5-year rates of reinterventions and TV patency were similar, thereby indicating that overall effectiveness of treatment remained satisfactory at mid-term.
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Affiliation(s)
- Mario D'Oria
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.,Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste-ASUGI, Trieste, Italy
| | - Jacob Budtz-Lilly
- Division of Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - David Lindstrom
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Goran Lundberg
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Jonsson
- Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Jon Unosson
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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Impact of proximal neck anatomy on short-term and mid-term outcomes after treatment of abdominal aortic aneurysms with new-generation low-profile endografts. Results from the multicentric "ITAlian north-east registry of ENDOvascular aortic repair with the BOltOn Treo endograft (ITA-ENDOBOOT)". Ann Vasc Surg 2021; 80:37-49. [PMID: 34752851 DOI: 10.1016/j.avsg.2021.08.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/25/2021] [Accepted: 08/30/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The aim of the study was to evaluate the short-term and mid-term technical and clinical outcomes of the Bolton Treo endograft in subjects with abdominal aortic aneurysm (AAA) requiring endovascular aortic repair (EVAR) and assess if presence of hostile proximal neck would represent a risk factor for increased failure rates. METHODS A retrospective review of all consecutive patients who had undergone elective or non-elective EVAR with the Bolton Treo endograft at five institutions located in the North-East of Italy (January 2016-December 2020) was performed. The main exposure variable for this study was presence of hostile (HAN) or friendly (FAN) aortic neck. RESULTS A total of 137 consecutive patients were treated with the Bolton Treo endograft at participating institutions; of these 63 (46%) presented HAN while 74 (54%) had FAN. At baseline, no significant differences were observed in the distribution of demographics and comorbidities between study groups. Two type Ia endoleaks (EL) were detected at completion angiography, all in patients with HAN but none in patients with FAN (3% vs 0%, p=.04), but no type III EL were identified in the whole cohort. The median duration of follow-up in the study cohort was 30 months (IQR 22-34 months) and was similar between study groups (p=.87). At three-years, survival estimates were 89% and 91% (p=.82) in patients with HAN and FAN, respectively. At three years, patients with HAN had significantly lower freedom from type IA endoleak as compared with patients with FAN (87% vs 94%, p=.02). No significant differences were found between study groups in the three-year estimates of freedom from reinterventions (80% vs 86%, p=.28). Using cox proportional hazards, presence of type II EL (HR 3.15, 95%CI 1.18-8.5, p=.02) and presence of type IA EL (HR 4.22, 95%CI 1.39-12.85, p=.01) were found as independent predictors for reinterventions in univariate analysis, although they were no longer significant in the multivariate model. Freedom from sac increase >5mm at three years were not significantly different between study groups (92% vs 91%, p=.95). CONCLUSIONS Within a contemporary multicentric real-world experience, EVAR with the Bolton Treo endograft shows a satisfactory safety profile in the immediate postoperative phase and acceptable outcomes during mid-term follow-up. Presence of HAN is correlated with development of type Ia EL (either early following stent-graft implantation or late after EVAR) which, in turn, may represent a significant factor leading to reinterventions.
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Lopez Espada C, Behrendt CA, Budtz-Lilly J, Mani K. The VASCUNExplanT Project: An International Collaborative Study Assessing Endovascular Aneurysm Repair Explantations. Eur J Vasc Endovasc Surg 2021; 62:817-818. [PMID: 34366256 DOI: 10.1016/j.ejvs.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/03/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Cristina Lopez Espada
- Department of Vascular Surgery, University Hospital Virgen de las Nieves, Granada, Spain.
| | - Christian-Alexander Behrendt
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Hostalrich A, Mesnard T, Soler R, Girardet P, Kaladji A, Jean Baptiste E, Malikov S, Reix T, Ricco JB, Chaufour X. Prospective Multicentre Cohort Study of Fenestrated and Branched Endografts After Failed Endovascular Infrarenal Aortic Aneurysm Repair with Type Ia Endoleak. Eur J Vasc Endovasc Surg 2021; 62:540-548. [PMID: 34364770 DOI: 10.1016/j.ejvs.2021.06.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 05/25/2021] [Accepted: 06/13/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Failed endovascular infrarenal aortic aneurysm repair (EVAR) due to development of late type Ia endoleak exposes patients to the risk of rupture and should be treated. The purpose of this study was to evaluate the results of fenestrated/branched EVAR (F/BEVAR) for treatment of failed EVAR with type Ia endoleak. METHODS From January 2010 to December 2019, a prospective multicentre study was conducted (ClinicalTrials.gov identifier: NCT04532450) that included 85 consecutive patients who had undergone F/BEVAR to treat a type Ia endoleak following EVAR. The primary outcome was overall freedom from any re-intervention or death related to the F/BEVAR procedure. RESULTS In 30 cases (35%) EVAR was associated with a short < 10 mm or angulated (> 60°) infrarenal aortic neck, poor placement of the initial stent graft (n = 3, 4%), sizing error (n = 2, 2%), and/or stent graft migration (n = 7, 8%). Type Ia endoleak was observed after a period of 59 ± 25 months following EVAR. The authors performed 82 FEVAR (96%) and three BEVAR (4%) procedures with revascularisation of 305 target arteries. Overall technical success was 94%, with three failures including one persistent Type Ia endoleak and two unsuccessful stent graft implantations. Intra-operative target artery revascularisation was successful in 303 of 305 attempts. The in hospital mortality rate was 5%. Cardiac, renal and pulmonary complications occurred in 6%, 14%, and 7% of patients, respectively. Post-operative spinal cord ischaemia occurred in four patients (4.7%). At three years, the survival rate was 64% with overall freedom from any re-intervention or aneurysm related death of 40%, and freedom from specific F/BEVAR re-intervention of 73%. At three years, the secondary patency rate of the target visceral arteries was 96%. During follow up, 27 patients (33%) required a revision procedure of the fenestrated (n = 11) or index EVAR stent graft (n = 16), including six open conversions. CONCLUSION While manufactured F/BEVAR was effective in treating type Ia endoleak in patients with failed EVAR, it was at the cost of a number of secondary endovascular and open surgical procedures.
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Affiliation(s)
- Aurélien Hostalrich
- Department of Vascular Surgery, University Hospital Rangueil, Toulouse, France
| | - Thomas Mesnard
- Department of Vascular Surgery, University Hospital, Lille, INSERM U1008, University of Lille, Lille, France
| | - Raphael Soler
- Department of Vascular Surgery, University Hospital La Timone, Marseille, France
| | - Paul Girardet
- Department of Vascular Surgery, University Hospital E. Herriot, Lyon, France
| | - Adrien Kaladji
- Department of Cardiothoracic and Vascular Surgery, University Hospital of Rennes, France
| | | | - Serguei Malikov
- Department of Vascular Surgery, University Hospital, Vandoeuvre les Nancy, France
| | - Thierry Reix
- Department of Vascular Surgery, University Hospital, Amiens, France
| | | | - Xavier Chaufour
- Department of Vascular Surgery, University Hospital Rangueil, Toulouse, France
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Okazaki T, Hamamoto M, Takasaki T, Katayama K, Kobayashi T, Takahashi S. Rupture of Abdominal Aortic Aneurysm Caused by Combined Type IIIb and Type Ia Endoleak with the Endurant II Endograft: A Case Report. Ann Vasc Dis 2021; 14:159-162. [PMID: 34239642 PMCID: PMC8241554 DOI: 10.3400/avd.cr.20-00175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 03/03/2021] [Indexed: 11/14/2022] Open
Abstract
We report a case of combined types IIIb and Ia endoleak that developed 6 years after endovascular aneurysm repair (EVAR) with the Endurant II® endograft for abdominal aortic aneurysm (AAA). The patient presented with post-EVAR AAA rupture and underwent emergency open repair. We observed types IIIb and Ia endoleak and successfully performed felt banding to preserve the stent graft. Type IIIb endoleak with the Endurant® endograft is rare, and treatments have not been fully established. We summarized the case reports regarding type IIIb endoleak with the Endurant® endograft and mainly discussed the treatments.
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Affiliation(s)
- Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi, Hiroshima, Japan
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi, Hiroshima, Japan
| | - Taiichi Takasaki
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Hiroshima, Japan
| | - Keijiro Katayama
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Hiroshima, Japan
| | - Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Hiroshima, Japan
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Xodo A, D'Oria M, Squizzato F, Antonello M, Grego F, Bonvini S, Milite D, Frigatti P, Cognolato D, Veraldi GF, Perkmann R, Garriboli L, Jannello AM, Lepidi S. Early and mid-term outcomes following open surgical conversion after failed endovascular aneurysm repair from the "Italian North-easT RegIstry of surgical Conversion AfTer Evar" (INTRICATE). J Vasc Surg 2021; 75:153-161.e2. [PMID: 34182022 DOI: 10.1016/j.jvs.2021.05.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 05/21/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To report the early and mid-term outcomes following open surgical conversion (OSC) after failed endovascular aortic repair (EVAR) using data from a multicentric registry. METHODS A retrospective study was carried out on consecutive patients undergoing OSC after failed EVAR at eight tertiary vascular units from the same geographic area in the North-East of Italy, from April 2005 to November 2019. Study endpoints included early and follow-up outcomes. RESULTS 144 consecutive patients were included in the study. Endoleaks were the most common indication for OSC (50.7%), with endograft infection (24.6%) and occlusion (21.9%) being the second most prevalent causes. The overall rate of 30-day all-cause mortality was 13.9% (n=20); 32 patients (22.2%) experienced at least one major complication. Mean length of stay (LoS) was 13 ± 12.7 days. On multivariate logistic regression, age (OR 1.09, 95% CI 1.01-1-19, p= .02), renal clamping time (OR 1.07, 95% CI 1.02-1.13, p= .01), and suprarenal/celiac clamping (OR 6.66, 95% CI 1.81-27.1, p= .005) were identified as independent predictors of peri-operative major complications. Age was the only factor associated with peri-operative mortality at 30 days. Renal clamping time > 25 minutes had sensitivity of 65% and specificity of 70% in predicting the occurring of major adverse events (AUC 0.72; 95% CI 0.61-0.82). At 5 years, estimated survival was significantly lower for patients treated due to aortic rupture/dissection (28%, 95% CI 13-61), compared to patients in whom the indication for treatment was endoleak (54%, 95% CI 40-73), infection (53%, 95% CI 30-94), or thrombosis (82%, 95% CI 62-100; p= .0019). 5-year survival rates were significantly lower in patients who received emergent treatment (28%, 95% CI 14-55) as compared with those who were treated in urgent (67%, 95% CI 48-93) or elective setting (57%, 95% CI 43-76; p= .00026). Subjects who received suprarenal/celiac (54%, 95% CI 36-82) or suprarenal (46%, 95% CI 34-62) aortic cross-clamping had lower survival rates at 5 years than those whose aortic-cross clamp site was infrarenal (76%, 95% CI 59-97; p= .041). Using multivariate Cox Proportional Hazard, older age and emergency setting were independently associate with higher risk for overall 5 years mortality. CONCLUSIONS OSC after failed EVAR was associated with relatively high rates of early morbidity and mortality, particularly for emergency setting surgery. Endoleaks with secondary sac expansion were the main indication for OSC and suprarenal aortic cross-clamping was frequently required. Endograft infection and emergent treatment remained associated with poorer short-term and long-term survival.
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Affiliation(s)
- Andrea Xodo
- Vascular and Endovascular Surgery Division, Padova University, School of Medicine, Padova, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University of Trieste Medical School, Trieste, Italy
| | - Francesco Squizzato
- Vascular and Endovascular Surgery Division, Padova University, School of Medicine, Padova, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Division, Padova University, School of Medicine, Padova, Italy
| | - Franco Grego
- Vascular and Endovascular Surgery Division, Padova University, School of Medicine, Padova, Italy
| | - Stefano Bonvini
- Department of Vascular Surgery, Santa Chiara Hospital, Trento, Italy
| | - Domenico Milite
- Operative Unit of Vascular and Endovascular Surgery, "S. Bortolo" Hospital, Vicenza, Italy
| | - Paolo Frigatti
- Vascular Surgery Department, University Hospital of Udine, Udine, Italy
| | - Diego Cognolato
- Vascular Surgery Department, "S. Bassiano" Hospital, Bassano del Grappa, Italy
| | | | | | - Luca Garriboli
- Department of Vascular Surgery, IRCCS Sacro Cuore Don Calabria, Negrar, Verona, Italy
| | | | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University of Trieste Medical School, Trieste, Italy.
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Mortola L, Ferrero E, Quaglino S, Ferri M, Viazzo A, Manzo P, Gaggiano A. Management of Nellix migration and type Ia endoleak from proximal endovascular aneurysm sealing relining to late open conversion. J Vasc Surg 2021; 74:1204-1213. [PMID: 33684472 DOI: 10.1016/j.jvs.2021.02.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 02/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite promising early results, mid-term failures of the Nellix endovascular aneurysm sealing (EVAS) system (Endologix Inc, Irvine, Calif) have been reported at higher than expected rates. The management of proximal endoleaks and migration differs from those after conventional endovascular aortic aneurysm repair (EVAR) owing to the peculiar design of the Nellix device. In the present study, we report a monocentric experience in the management of EVAS complications using various techniques. We also performed a comprehensive review of the relevant literature on both open surgical and endovascular management of proximal failure of EVAS from the MEDLINE database. METHODS We retrospectively analyzed the reinterventions for type Ia endoleak and migration after elective infrarenal EVAS at our institution. We collected preoperative, intraoperative, and follow-up data. Open and endovascular techniques are described. Overall survival, aortic-related mortality, and the technical success rate (rate of exclusion of endoleaks) with endovascular techniques were the primary outcomes. RESULTS We performed 101 infrarenal elective EVAS procedures from 2013 to 2018. Of the 101 patients, 20 (19.8%) had required reintervention for proximal sealing failure. The indications were type Ia (Is2, Is3) endoleak, migration >5 mm, sac expansion >5 mm, and secondary rupture. Of the 20 patients, 6 (30%) were treated with endovascular techniques-2 with a chimney Nellix-in-Nellix application and 4 with proximal relining with a covered stent. The remaining 14 patients (70%) were treated with late open conversion (OC). The average time from EVAS to reintervention was 36.1 months (range, 3-65 months). Six patients (30%) had undergone OC in an emergent setting because of secondary rupture. The technical success rate for the patients treated with endovascular reinterventions was 100%. The 30-day mortality was 20% (4 of 20), all emergent cases (four of six emergent repairs; 67%). The overall survival for the 20 patients was 75% (n = 15) at a mean follow-up of 15.1 months (range, 2-47 months). One patient had died after 7 months of non-aortic-related causes. CONCLUSIONS The high reintervention rate of the Nellix graft mandates careful evaluation for its further use with the revised instructions for use, and it should not be used off-label. OC remains the strategy of choice when managing Nellix proximal sealing failures in fit patients. Chimney Nellix-in-Nellix application and transcatheter embolization are feasible alternative techniques. Proximal relining also appears to be an effective alternative to more complex interventions, although it requires further studies for validation.
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Affiliation(s)
- Lorenzo Mortola
- Vascular and Endovascular Surgery Unit, University Hospital of Novara, Novara, Italy.
| | - Emanuele Ferrero
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Simone Quaglino
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Michelangelo Ferri
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Andrea Viazzo
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Paola Manzo
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Andrea Gaggiano
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
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A Canadian multicenter experience describing outcomes after endovascular abdominal aortic aneurysm repair stent graft explantation. J Vasc Surg 2021; 74:720-728.e1. [PMID: 33600929 DOI: 10.1016/j.jvs.2021.01.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 01/06/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Most studies describing the outcomes after endovascular abdominal aortic aneurysm repair (EVAR) explantation have been from single, high-volume, centers. We performed a multicenter cross-Canadian study of outcomes after EVAR stent graft explantation. Our objectives were to describe the outcomes after late open conversion and EVAR graft explantation at various Canadian centers and the techniques and outcomes stratified by the indication for explant. METHODS The Canadian Vascular Surgery Research Group performed a retrospective multicenter study of all cases of EVAR graft explantation at participating centers from 2003 to 2018. Data were collected using a standardized, secure, online platform (RedCap [Research Electronic Data Capture]). Univariate statistical analysis was used to compare the techniques and outcomes stratified the indication for graft explantation. RESULTS Patient data from 111 EVAR explants collected from 13 participating centers were analyzed. The mean age at explantation was 74 years, the average aneurysm size was 7.5 cm, and 28% had had at least one instructions for use violation at EVAR. The average time between EVAR and explantation was 42.5 months. The most common indication for explantation was endoleak (n = 66; type Ia, 46; type Ib, 2; type II, 9; type III, 2; type V, 7), followed by infection in 20 patients; rupture in 18 patients (due to type Ia endoleak in 10 patients, type Ib in 1, type II in 1, type III in 2, and type V in 1), and graft thrombosis in 7 patients. The overall 30-day mortality was 11%, and 45% of the patients had experienced at least one major perioperative complication. Mortality was significantly greater for patients with rupture (33.3%) and those with infection (15%) compared with patients undergoing elective explantation for endoleak (4.5%; P = .003). The average center volume during the previous 15 years was 8 cases with a wide range (2-19 cases). A trend was seen toward greater mortality for patients treated at centers with fewer than eight cases compared with those with eight or more cases (19% vs 9%). However, the difference did not reach statistical significance (P = .23). Overall, 41% of patients had undergone at least one attempt at endovascular salvage before explantation, with the highest proportion among patients who had undergone EVAR explantation for endoleak (51%). Only 22% of patients with rupture had undergone an attempt at endovascular salvage before explantation. CONCLUSIONS The performance of EVAR graft explantation has increasing in Canada. Patients who had undergone elective explantation for endoleak had lower mortality than those treated for either infection or rupture. Thus, patients with an indication for explanation should be offered surgery before symptoms or rupture has occurred. A trend was seen toward greater mortality for patients treated at centers with lower volumes.
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Makaloski V, Tsilimparis N, Panuccio G, Spanos K, Wyss TR, Rohlffs F, Debus ES, Kölbel T. Perioperative Outcome of Fenestrated and Branched Stent Grafting after Previous Open or Endovascular Abdominal Aortic Repair. Ann Vasc Surg 2021; 74:229-236. [PMID: 33549779 DOI: 10.1016/j.avsg.2020.12.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND To compare the perioperative outcome of patients treated with elective or urgent fenestrated and branched stent grafting (fbEVAR) for pararenal (pAAA) and thoracoabdominal aortic aneurysm (TAAA) after previous open with previous endovascular abdominal aortic repair. METHODS Single center retrospective analysis of all patients undergoing fbEVAR after previous open (post-open fbEVAR group) or endovascular abdominal aortic repair (post-endo fbEVAR group) between January 2015 and December 2017. Primary outcomes were technical success and in-hospital all-cause mortality. RESULTS We identified 42 patients undergoing fbEVAR after previous open or endovascular abdominal aortic repair during this period. Twenty-one patients (post-open fbEVAR group) had previous open abdominal aortic repair, 13 with a bifurcated and 8 with a tube graft. Of these, 2 patients presented with pAAA and 19 with TAAA. Twenty-one patients (post-endo fbEVAR group) had previous EVAR. Thirteen patients presented with pAAA, 3 of them with additional type Ia endoleak, 2 with stent-graft migration and 2 with previously failed fEVAR. Eight presented with TAAA. Median interval between previous repair and fbEVAR was 84 months (IQR 60-156) for the post-open fbEVAR group and 72 months (IQR 36-96) for the post-endo fbEVAR group (P = 0.746). Eighteen patients (86%) had branched stent grafting in the post-open versus 11 (52%) in the post-endo group (P < 0.01). In 2 patients in the post-open group, 3 renal arteries were not catheterized due to severe ostial stenosis, resulting in technical success of 91% in the post-open and 100% in the post-endo fbEVAR group. Four patients (19%) in the post-open fbEVAR group died in hospital, 2 due to cerebral hemorrhage and 2 due to pneumonia, and none in the post-endo fbEVAR group (P = 0.101). There were 5 nonstent-graft-related reinterventions, 2 (10%) in the post-open fbEVAR group and 3 (14%) in the post-endo fbEVAR group (P = 0.844). After 12 months there were 4 events in the post-endo fbEVAR group: one renal artery stent occluded, one renal artery stent required relining because of disconnection and 2 type II endoleaks were embolized with coils. There were no reinterventions in the post-open fbEVAR group during 12 months. CONCLUSIONS Fenestrated and branched repair after previous open or endovascular abdominal aortic repair appears safe with high technical success rate. There is no difference in the technical success and in-hospital all-cause mortality rates between fbEVAR after previous open or endovascular abdominal aortic repair.
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Affiliation(s)
- Vladimir Makaloski
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany; Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Nikolaos Tsilimparis
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Thomas Rudolf Wyss
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Eike Sebastian Debus
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany
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Fairman AS, Chin AL, Jackson BM, Foley PJ, Damrauer SM, Kalapatapu V, Golden MA, Fairman RM, Wang GJ. The evolution of open abdominal aortic aneurysm repair at a tertiary care center. J Vasc Surg 2020; 72:1367-1374. [DOI: 10.1016/j.jvs.2019.12.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 12/17/2019] [Indexed: 10/24/2022]
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Lessons Learned from Open Surgical Conversion after Failed Previous EVAR. Ann Vasc Surg 2020; 71:356-369. [PMID: 32890649 DOI: 10.1016/j.avsg.2020.08.122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Delayed open conversion (OpC) after endovascular aortic aneurysm repair (EVAR) is becoming increasingly common worldwide. We reviewed our experience to characterize the perioperative spectrum of OpC repairs. MATERIALS AND METHODS A retrospective analysis of a prospectively maintained institutional database to identify patients who underwent late OpC after failed EVAR was performed. Patient and aneurysm baseline characteristics, mechanism of failure, perioperative details, including type of repair/complications/survival, and late outcomes were examined. RESULTS From January 2003 to January 2020, 38 male patients (mean age, 75 ± 7 years; range, 60-90) required late OpC. Interval time from initial EVAR to OpC was 63.6 ± 33.8 months (range, 17-120). Mean diameter of the aneurysms was 82.2 ± 22.1 mm before OpC compared with 62.9 ± 13 mm before endograft implantation. Mechanisms of failure were type Ia, Ib, II, and III endoleaks in 14 (36.8%), 9 (23.7%), 4 (10.5%), and 1 (2.6%) patient(s), respectively; infection in 3 (7.9%), leg ischemia in 2 (5.3%), and multiple causes in 5 (13.2%) patients. We observed 4 (10.5%) asymptomatic, 16 (42.1%) symptomatic, and 18 (47.3%) ruptured aneurysms. Four patients (10.5%) had stable contained ruptures, whereas the remaining 13 (34.2%) and 1 additional patient (2.6%) with aortoenteric fistula presented with hemorrhagic shock (class ≥II). Total endograft explantation, endograft preservation, or proximal/distal partial graft removal was performed in 16 (42.1%), 10 (26.3%), and 2 (5.2%)/9 (23.7%) of patients, respectively. Technical success was 100%, excluding an early postaortic clamping death. Overall, 30-day mortality was 21.1% (8 of 38) and significantly higher in patients with hemorrhagic shock or hemodynamic instability at presentation (P = 0.04 and P = 0.009, respectively) and in patients who had endografts with hooks/barbs or experiencing higher postoperative complication rate (P = 0.02 and P = 0.006, respectively). By definition, procedure success was 81.1%. Mean follow-up was 37.6 ± 39.8 months. By the end of the study, we recorded 11 deaths (2 were aneurysm related). CONCLUSIONS Despite high technical success, OpC has a significant mortality in patients presenting with hemorrhagic shock and had active fixation endografts or experiencing high complication rate. Many other confounding factors may play a role.
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Fanelli M, Massoni CB, Bramucci A, Perini P, Freyrie A. Complete Relining in Type 3 Endoleak with AFX Endograft Billowing and Severe Kinking: A Case Report. Ann Vasc Surg 2020; 69:451.e11-451.e16. [PMID: 32634566 DOI: 10.1016/j.avsg.2020.06.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 06/12/2020] [Accepted: 06/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Type 3 endoleak (T3E) is usually treated by endovascular relining. The procedure can be technically complex in cases of endografts with kinking of innermost stents. We report a case of T3E in an AFX (Endologix, Irvine, CA, USA) endograft with sac enlargement, billowing, and severe kinking of the main body stents, managed with a complete relining endovascular procedure. METHODS A 69-year-old man with severe comorbidities and prior aorto-bi-iliac AFX endograft completed by an Endurant II cuff (Medtronic, Santa Rosa, CA, USA) for a 63-mm asymptomatic infrarenal aneurysm was admitted to our department for a T3E with 7-mm sac enlargement. The computed tomography angiography (CTA) showed perfusion of the aneurysmal sac, AFX fabric disconnection from its stent (billowing), and severe stent kinking of the main body without a residual lumen. A digital subtraction angiography confirmed the T3E. A complete relining was performed by deploying a bifurcated Endurant II through the AFX stents. RESULTS The 1-year CTA proved the resolution of the endoleak with a stable aneurysmal sac diameter. CONCLUSIONS In case of T3E with severe main body stent kinking and graft billowing, an endovascular procedure with a complete aorto-bi-iliac relining through inner stents may be considered.
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Affiliation(s)
- Mara Fanelli
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy.
| | | | - Alberto Bramucci
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
| | - Paolo Perini
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
| | - Antonio Freyrie
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
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Surgical "New Aortic Carrefour Technique" for Late Open Conversion After Endovascular Aortic Repair. Ann Vasc Surg 2020; 70:434-443. [PMID: 32599108 DOI: 10.1016/j.avsg.2020.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND The aim of the study is to report the early and midterm outcomes of late open conversion (LOC) after endovascular aortic repair (EVAR) using the "new aortic carrefour technique" (NACT) for preservation of the stent-graft iliac limbs. Late conversions were defined as explants >6 months after previous EVAR. METHODS Patients treated for elective or urgent LOC after EVAR with the NACT at a single center (2009-2019), and with ≥6 months of follow-up, were included. Briefly, after completing the proximal aortic anastomosis, the endograft iliac limbs were truncated and sutured together to create a "new aortic carrefour" (Veraldi's technique). A Dacron-knitted straight graft was therefore sutured to the newly created aortic bifurcation. Outcomes of interest were as follows: immediate technical success, intraoperative characteristics, and reinterventions. Results are reported as the number (and percentages) or median (and interquartile range [IQR]). RESULTS During the study period, 433 patients underwent standard EVAR for abdominal aortic aneurysm and 20 underwent LOC. Of these, 9 consecutive patients were deemed suitable and treated with NACT. The indication for conversion was endoleak in 6 (type IA n = 1, type II n = 4, type III n = 1), complete graft thrombosis (n = 2), and one case of sac enlargement without any clear signs of endoleak at computed tomography angiography. Of these cases, six were treated electively, while three were treated in urgent setting including one case of rupture. The median procedure, aortic cross-clamping, and distal anastomosis times were 280 minutes (IQR: 225-290), 24 minutes (IQR: 22-29), and 15 minutes (IQR: 14-18), respectively. The median blood loss was 1,600 mL (IQR: 700-1,900), and the median hospital stay was 8 days (IQR 7-12). None of the patients died and neither required unplanned reintervention within 30 days. At a median imaging follow-up of 13 months (IQR 8-43), there were no reinterventions due to residual leaks or technical defects. One patient died during follow-up, and the recorded cause of death was heart failure. CONCLUSIONS The use of the NACT with preservation of the original endograft iliac limbs for LOC after EVAR is a safe and feasible technique, which results in a low perioperative morbidity and mortality rate in selected patients. The technique is effective during midterm follow-up and might represent a valuable tool to expand the armamentarium of vascular surgeons for surgical regrafting after EVAR.
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Chastant R, Canaud L, Ozdemir BA, Aubas P, Molinari N, Picard E, Branchereau P, Marty-Ané CH, Alric P. Elective late open conversion after endovascular aneurysm repair is associated with comparable outcomes to primary open repair of abdominal aortic aneurysms. J Vasc Surg 2020; 73:502-509.e1. [PMID: 32473342 DOI: 10.1016/j.jvs.2020.05.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 05/06/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Three of four patients with infrarenal abdominal aortic aneurysm are now treated with endovascular aneurysm repair (EVAR). The incidence of secondary procedures and surgical conversions is increasing for a population theoretically unfit for open surgery. The indications and outcomes of late open surgical conversions after EVAR in a high-volume tertiary vascular unit are reported. METHODS This retrospective single-center study includes all patients who underwent a late open conversion between January 1996 and July 2018. Data were collected from records on patient demographics, operative indications, surgical strategy, perioperative outcomes, and medium-term survival. RESULTS Sixty-two consecutive patients (88.7% male) with a mean age of 77.5 years are included. The median duration since index EVAR was 38.5 months; 65% of stent grafts requiring late open conversion had suprarenal fixation. Indications included 22.6% type IA, 16.1% type IB, and 45.2% type II endoleaks; 12.9% graft thrombosis; and 14.5% endoprosthesis infection. Complete endograft explantation was performed in 37.1% of patients and a partial explantation in 54.8%, whereas 8.1% of stent grafts were wholly preserved in situ. Overall 30-day mortality was 12.9% (n = 8) in the cohort and 2.7% for elective patients. The all-cause morbidity rate was 40.1%, and the median length of hospital stay was 9 days. After follow-up of 28.4 months (range, 1.8-187.3 months), all-cause survival was 58.8%. Avoidance of aortic clamping (P = .006) and elective procedures (P = .019) were associated with a significant reduction in the length of hospital stay. Moreover, the 30-day mortality (P = .002), occurrence of postoperative renal dysfunction (P = .004), and intestinal ischemia (P = .017) were increased in the emergency setting. Excluding cases with rupture or infection, survival estimates were 97%, 97%, and 71% at 1 year, 2 years, and 5 years, respectively. CONCLUSIONS Technically more complex than primary open surgery, late open conversion is a procedure that generates an acceptable perioperative risk when it is performed in a high-volume aortic surgical center. Elective open conversion is associated with excellent early and late outcomes. Endograft preservation strategies decrease perioperative morbidity.
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Affiliation(s)
- Robin Chastant
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.
| | - Ludovic Canaud
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Baris Ata Ozdemir
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France; Vascular and Endovascular Department, North Bristol NHS Trust and University of Bristol, Bristol, United Kingdom
| | - Pierre Aubas
- Department of Medical Information, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Nicolas Molinari
- Department of Medical Information, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Eric Picard
- Department of Vascular and Thoracic Surgery, Caremeau Hospital, Nimes, France
| | - Pascal Branchereau
- Department of Vascular and Thoracic Surgery, Caremeau Hospital, Nimes, France
| | - Charles-Henri Marty-Ané
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Pierre Alric
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
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Eleshra A, Oderich GS, Spanos K, Panuccio G, Kärkkäinen JM, Tenorio ER, Kölbel T. Short-term outcomes of the t-Branch off-the-shelf multibranched stent graft for reintervention after previous infrarenal aortic repair. J Vasc Surg 2020; 72:1558-1566. [PMID: 32423775 DOI: 10.1016/j.jvs.2020.02.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 02/03/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the outcome of t-Branch (Cook Medical, Bloomington, Ind) stent graft for the treatment of thoracoabdominal and pararenal aortic aneurysms in patients who had previous infrarenal aortic repair. METHODS A retrospective two-center study was undertaken. All consecutive patients who underwent endovascular repair using t-Branch stent graft after previous infrarenal aortic repair between January 2010 and August 2018 were included. Demographics, past medical history, cardiovascular risk factors, and intraoperative and perioperative details were recorded. Technical success and early (30-day) mortality, morbidity, target vessel patency, and presence of endoleak were analyzed. During the first year of follow-up, survival, freedom from reintervention, and patency rates were recorded. RESULTS There were 32 patients (mean age, 74 ± 7 years; 81% male) included in the study; 24 (75%) patients had prior open surgical repair, and 8 (25%) patients had undergone standard endovascular aneurysm repair. The index operation was performed 9 ± 5 years earlier, including 10 ± 5 years for open surgical repair and 8 ± 6 years for endovascular aortic repair. The indication was progression of the disease in 26 patients (81%) and type IA endoleak in 6 patients (19%). The total number of target vessels incorporated was 117 arteries (3.8 ± 0.6 target vessels per patient). Eleven patients had only three vessels incorporated; celiac trunk was occluded in three patients, and eight patients had one functioning kidney. Technical success rate was 97% (31/32). There was a single technical failure in one patient who had a type IA endoleak after endovascular repair with suprarenal fixation. The stenotic right renal artery was not catheterized at the initial procedure, and retrograde access was achieved through a right subcostal incision 3 days later with successful completion of the repair. Early mortality rate was 13%, and spinal cord ischemia rate was 22% (7/32); four patients had permanent and three had transient neurologic deficits. Early target vessel patency was 100%, and the rate of any endoleak was 9% (3/32); two patients had type II endoleaks and one patient had type III endoleak. The mean follow-up was 5.4 ± 5.9 months. The cumulative survival rate was 82% and 73% at 6 and 12 months, respectively. The freedom from aorta-related mortality was 92% at 6 and 12 months. The cumulative freedom from reintervention during follow-up was 90% at 6 and 12 months. The overall target vessel patency rate was 100% and 97.5% at 6 and 12 months, respectively. CONCLUSIONS The use of t-Branch off-the-shelf stent graft for the treatment of aortic disease in patients who had previous infrarenal aortic repair appears to be feasible, with acceptable early outcomes in terms of morbidity and mortality.
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Affiliation(s)
- Ahmed Eleshra
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany.
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, Minn
| | - Konstantinos Spanos
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Giuseppe Panuccio
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Jussi M Kärkkäinen
- Division of Vascular and Endovascular Surgery, Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, Minn
| | - Emanuel R Tenorio
- Division of Vascular and Endovascular Surgery, Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, Minn
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
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Twenty-two Year Multicentre Experience of Late Open Conversions after Endovascular Abdominal Aneurysm Repair. Eur J Vasc Endovasc Surg 2020; 59:757-765. [DOI: 10.1016/j.ejvs.2020.01.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 11/29/2019] [Accepted: 01/10/2020] [Indexed: 11/24/2022]
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Perini P, Bianchini Massoni C, Mariani E, D'ospina RM, Rossi G, Carli AG, Bramucci A, Azzarone M, Freyrie A. Late open conversions after failed EVAR. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2019. [DOI: 10.23736/s1824-4777.19.01419-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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