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Vakhitov D, Grandhomme J, Kuntz S, Christ L, Neumann N, Heim F, Chakfé N, Lejay A. Editor's Choice -- Type IIIb Endoleaks: Fabric Perforations of Explanted New Generation Endoprostheses. Eur J Vasc Endovasc Surg 2024; 67:446-453. [PMID: 37717814 DOI: 10.1016/j.ejvs.2023.09.019] [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: 05/11/2023] [Revised: 08/20/2023] [Accepted: 09/11/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVE To analyse explanted endografts (EGs) and describe fabric degradation responsible for type IIIb endoleaks. METHODS As part of the European collaborative retrieval programme, 32 EGs with fabric defects on macroscopic evaluation were selected. The explanted EGs were processed and studied based on the ISO 9001 certified standard protocol. It includes instructions on the collection, transportation, cleaning, and examination of explanted material. The precise analysis was performed with a digital microscope of 20 - 200 times magnification. Possible perforation mechanisms were assessed in stress tests. RESULTS The median time to explantation of the 32 EGs was 54 months. The explants included 65 separate EG modules, with 46 (70.8%) having a combined 388 fabric perforations. Each EG had a median of 4.79 mm2 (interquartile range [IQR] 9.86 mm2) of cumulated hole area (an average of 0.13% of an EG's area). There were 239 (61.6%) expanded polytetrafluoroethylene (ePTFE; 11 EGs) and 149 (38.4%) polyethylene terephthalate (PET; 21 EGs) fabric ruptures, with no difference in hole distribution between these types of material. Overall, 126 (32.5%) stent related and 262 (67.5%) non-stent related fabric perforations were identified. Perforations caused by fabric fatigue in ePTFE (151, 63.2%) and material kinking in PET (41, 27.5%) were the most common. The stent related perforations were larger in size (0.80 mm2) than non-stent related perforations (0.19 mm2); p < .001. Wider interstent spaces and prolonged implantation duration were associated with an increased risk of stent related perforation development; p < .001 and p = .004, respectively. Large stent related perforations were also detected in the short term, suggesting mechanical issues as underlying causes. CONCLUSION The fabric of EGs may degrade and lead to the development of perforations. The largest perforations are stent related. Their occurrence and size depend on the implantation time and the EG shape affected by arterial tortuosity. The conclusions are limited to the samples from a select explant group.
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Affiliation(s)
| | - Jonathan Grandhomme
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Salomé Kuntz
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | | | | | - Frédéric Heim
- GEPROMED, Strasbourg, France; Laboratoire de Physique et Mécanique Textile, Université de Haute-Alsace, Mulhouse, France
| | - Nabil Chakfé
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Anne Lejay
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
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Zuccon G, D'Oria M, Gonçalves FB, Fernandez-Prendes C, Mani K, Caldeira D, Koelemay M, Bissacco D, Trimarchi S, Van Herzeele I, Wanhainen A. Incidence, Risk Factors, and Prognostic Impact of Type Ib Endoleak Following Endovascular Repair for Abdominal Aortic Aneurysm: Scoping Review. Eur J Vasc Endovasc Surg 2023; 66:352-361. [PMID: 37356703 DOI: 10.1016/j.ejvs.2023.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 05/23/2023] [Accepted: 06/17/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE The primary objectives of this scoping review were to assess the rate of and risk factors for type Ib endoleak and to evaluate the extent of the evidence base that links type Ib endoleak to short and long term outcomes in patients undergoing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). METHODS Potentially eligible studies were searched in the Cochrane Central Register of Controlled Trials, MEDLINE, Web of Science Core Collection, SciELO Citation Index, Russian Science Citation Index, and KCI-Korean Journal Database. A scoping review was performed according to PRISMA extension for Scoping Reviews. RESULTS A total of 27 articles (four prospective registries and 23 retrospective cohort studies) dealing with type Ib endoleak were included in the final analysis. The number of patients reported on was 7 197, with follow up ranging between 12 months and 93 months. The reported frequency of type Ib endoleak in patients treated with EVAR ranged from 0% to 8%, Patient and or procedure related factors associated with risk of type Ib endoleak were (1) common iliac artery (CIA) diameter ˃ 18 mm requiring use of flared stent graft limbs (FLs) ˃ 20 mm, (2) length of CIA landing zone ˂ 20 mm, (3) marked iliac tortuosity, and (4) large initial AAA diameter. Depending on the study, 50 - 100% of type Ib endoleaks were corrected by endovascular means, with a reported immediate technical success of 100% in the studies providing this information. CONCLUSION Type Ib endoleak after EVAR has been reported to occur in 0 - 8% of cases. Several anatomical features, including CIA diameter ˃ 18 mm or requiring the use of FLs ˃ 20 mm, length of CIA landing zone ˂ 20 mm, marked iliac tortuosity, and large initial AAA diameter, could increase the risk of type Ib endoleak and may require alternative therapeutic options and or more stringent follow up. Therefore, this updated scoping review provides a comprehensive summary of the frequency, risk factors, prognosis, and treatment of type Ib endoleaks, and has identified knowledge gaps in the literature to guide further studies.
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Affiliation(s)
- Gianmarco Zuccon
- Vascular Division, Cardiovascular Department, HPG23 Hospital, Bergamo, Italy. http://www.twitter.com/MarioDoria14
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy.
| | - Frederico Bastos Gonçalves
- NOVA Medical School - Faculdade de Ciências Médicas (NMS|FCM), Universidade Nova de Lisboa, Lisbon, Portugal
| | | | - Kevin Mani
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Daniel Caldeira
- Serviço de Cardiologia, Hospital Universitário de Santa Maria - CHULN, Portugal; Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), CAML, CEMBE, Faculdade de Medicina, Universidade de Lisboa, Portugal; Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Mark Koelemay
- Department of Surgery, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Daniele Bissacco
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Santi Trimarchi
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Anders Wanhainen
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Peri-operative and Surgical Sciences, Surgery, Umeå University, Umeå, Sweden
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Kontopodis N, Galanakis N, Charalambous S, Matsagkas M, Giannoukas AD, Tsetis D, Ioannou CV, Antoniou GA. Editor's Choice - Endovascular Aneurysm Repair in High Risk Patients: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2022; 64:461-474. [PMID: 35872342 DOI: 10.1016/j.ejvs.2022.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 06/06/2022] [Accepted: 07/10/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To investigate outcomes of endovascular aneurysm repair (EVAR) in high risk patients. METHODS Bibliographic sources (MEDLINE, EMBASE, CINAHL, and CENTRAL) were searched using combinations of thesaurus and free text terms. The review protocol was registered in PROSPERO (CRD42021287207) and reported according to PRISMA 2020. Pooled estimates were calculated using odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI) applying the Mantel-Haenszel or inverse variance method. EVAR peri-operative mortality in high risk patients over time was examined with mixed effects meta-regression. The GRADE framework was used to rate the certainty of evidence. RESULTS The pooled peri-operative mortality in 18 416 high risk patients who underwent EVAR was 3% (95% CI 2.3 - 4%) and has significantly reduced over time (year of publication p = .003; median study point p = .023). The peri-operative mortality was significantly lower in high risk patients treated with EVAR compared with open repair (OR 0.64; 95% CI 0.45 - 0.92), but no significant difference was found in overall (HR 1.06; 95% CI 0.76 - 1.49) or aneurysm related mortality (HR 0.57; 95% CI 0.21 - 1.55). No significant difference was found in overall mortality between high risk patients treated with EVAR vs. no intervention (HR 0.42; 95% CI 0.14 - 1.26), but the aneurysm related mortality was significantly lower in the former (HR 0.30; 95% CI 0.14 - 0.63). The peri-operative mortality was higher in high risk than normal risk patients treated with EVAR (OR 2.33; 95% CI 1.75 - 3.10), as was the overall mortality (HR 3.50; 95% CI 2.55 - 4.80). The certainty of evidence was very low for EVAR vs. open surgery or no intervention and low for high vs. normal risk patients. CONCLUSION The EVAR peri-operative mortality in high risk patients has improved over time. Even though the aneurysm related mortality of EVAR is lower compared with no intervention, EVAR may confer no overall survival benefit.
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Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Department, Medical School, University of Crete, Heraklion, Greece
| | - Nikolaos Galanakis
- Interventiona Radiology Unit, Medical School, University of Crete, Heraklion, Greece
| | - Stavros Charalambous
- Interventiona Radiology Unit, Medical School, University of Crete, Heraklion, Greece; Department of Radiology, Division of Interventional Radiology, Nicosia General Hospital, Nicosia, Cyprus
| | - Miltiadis Matsagkas
- Vascular Surgery Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Vascular Surgery Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios Tsetis
- Interventiona Radiology Unit, Medical School, University of Crete, Heraklion, Greece
| | - Christos V Ioannou
- Vascular Surgery Department, Medical School, University of Crete, Heraklion, Greece
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom.
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Oliveira NFG, Bastos Gonçalves F, Verhagen HJM. Re: A Five-Year Computed Tomography Follow-up Study of Proximal Aortic Neck Dilatation After Endovascular Aortic Repair Using Four Contemporary Types of Endograft. Cardiovasc Intervent Radiol 2022; 45:270-271. [PMID: 35001151 DOI: 10.1007/s00270-021-03022-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 09/25/2021] [Indexed: 11/02/2022]
Affiliation(s)
- Nelson F G Oliveira
- Department of Vascular Surgery, Erasmus University Medical Centre, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. .,Department of Angiology and Vascular Surgery, Hospital Do Divino Espírito Santo, Ponta Delgada, Azores, Portugal. .,Hospital do Divino Espírito Santo, Ponta Delgada Avenida D. Manuel I, São Miguel Azores, 9500-782, Ponta Delgada, Portugal.
| | - Frederico Bastos Gonçalves
- Department of Vascular Surgery, Erasmus University Medical Centre, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.,Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
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Bogdanovic M, Stackelberg O, Lindström D, Ersryd S, Andersson M, Roos H, Siika A, Jonsson M, Roy J. Limb Graft Occlusion Following Endovascular Aneurysm Repair for Infrarenal Abdominal Aortic Aneurysm with the Zenith Alpha, Excluder, and Endurant Devices: a Multicentre Cohort Study. Eur J Vasc Endovasc Surg 2021; 62:532-539. [PMID: 34266764 DOI: 10.1016/j.ejvs.2021.05.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 03/26/2021] [Accepted: 05/08/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Limb graft occlusion (LGO) is a serious complication after endovascular aneurysm repair (EVAR) and while device development enables treatment of increasingly complex aortic anatomy, little is known about how endograft type affects the risk of occlusion. This observational study aimed to explore the incidence of LGO after EVAR for three major endograft systems. METHODS All patients with standard EVAR as the primary intervention for infrarenal abdominal aortic aneurysm (AAA), between January 2012 and December 2018, at five Swedish vascular surgery centres, were included in this multicentre retrospective cohort study. LGO was defined as a total limb occlusion regardless of symptoms, or a treated significant stenosis. A nested case control (NCC) design with incidence density sampling of 1:3 was used for analysis of potential per-operative and morphological risk factors. Conditional logistic regression was used to estimate multivariable odds ratios (OR) with 95% confidence intervals (CI) RESULTS: A total of 924 patients were included. The majority were male (84%), the mean age was 76 years (± 7.5 SD), and median AAA diameter was 59 mm (IQR 55, 67). Patients were treated with Zenith Alpha (n = 315, ZISL limbs), Excluder (n = 152, PLC/PXC limbs), and Endurant (n = 457, ETLW/ ETEW limbs). During median follow up of 37 months (IQR 21, 62), 55 occlusions occurred (5.9%); 39 with Zenith Alpha (12.4%), one with Excluder (0.7%), and 15 with Endurant (3.3%). In the NCC analysis, the Zenith Alpha device (OR 5.31, 95% CI 1.97 - 14.3), external iliac artery (EIA) landing (OR 5.91, 95% CI 1.30 - 26.7), and EIA diameter < 10 mm (OR 4.99, 95% CI 1.46 - 16.9) were associated with an increased risk of LGO. CONCLUSION Endograft device type is an independent risk factor for LGO after EVAR. Specifically, the Zenith Alpha demonstrated an increased risk of LGO compared with the Endurant and Excluder devices. In addition, a narrow EIA and landing zone in EIA are also risk factors for LGO.
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Affiliation(s)
- Marko Bogdanovic
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Otto Stackelberg
- Department of Clinical Science and Education, Karolinska Institutet at Södersjukhuset, Stockholm, Sweden; Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - David Lindström
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Samuel Ersryd
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Centre for Research and Development, Uppsala University/County Council of Gävleborg, Gävle, Sweden
| | - Manne Andersson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Surgery, Division of Vascular Surgery, Ryhov County Hospital, Jönköping, Sweden
| | - Håkan Roos
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Division of Vascular Surgery, Ryhov County Hospital, Jönköping, Sweden
| | - Antti Siika
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Jonsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
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