Long-term outcomes of infrarenal endovascular aneurysm repair with a commercially available stent graft

Estimation of the Added Cancer Risk Derived From EVAR and CTA Follow-Up

OBJECTIVE

The aim of this study was to assess the risk of radiation-induced cancer development in patients that have undergone an infrarenal EVAR, stratifying the relative contributions of the procedure and the preoperative and postoperative CTAs.

METHODS AND MATERIALS

The organ-specific absorbed radiation doses from CTA and the EVAR procedure were estimated from the radiation exposures of 95 and 45 male patients, respectively. Lifetime attributable risk (LAR) cancer predictions were calculated for 14 different organs. Life expectancy was assumed from a previous cohort of patients undergoing infra-renal EVAR.

RESULTS

The calculated total excess cancer risk was 0.0046, ie, 1 out of 220 patients will develop a neoplasm after being exposed to the ionizing radiation from the preoperative CTA, the EVAR and annual CTA examinations for 15 years. The procedure and the preoperative CTA contributed with 38% of the total excess risk, while the rest was derived from the follow-up. If the entire CTA based follow-up would have been eliminated, an excess risk of 0.0018 (1/560) would remain.

CONCLUSIONS

1 out of 219 patients who have undergone EVAR of an infra-renal AAA have a lifetime risk of developing cancer secondary to the radiation exposures related to the procedure and the CTAs used preoperatively and during follow-up. This risk derives mostly from the yearly postoperative CTAs, underlining the potential benefits of reducing or replacing their use.

CLINICAL IMPACT

A simulation-based estimation reinforced the potential deleterious effects of the radiation exposure for patients undergoing Endovascular Aneurysm Repair (EVAR) of Abdominal Aortic Aneurysms (AAA) and subsequently followed by yearly Computer Tomography Angiographies (CTAs). The risk could be as high as 1 out 219 patients developing a neoplasm after 15 years. The largest exposure derives from the follow-up CTAs and efforts to minimize their use as well as the intraoperative radiation are greatly needed. The simulation-based estimations done in this study reinforce potential deleterious effects of the radiation exposure for patients undergoing EVAR of AAA. Efforts should be done to minimize the intraoperative radiation and the number of CTAs used during follow-up.

Japanese single-center experience of abdominal aortic aneurysm repair over 20 years: should open or endovascular aneurysm repair be performed first?

PURPOSE

The present study analyzed the outcomes of our experience with abdominal aortic aneurysm (AAA) repair over 20 years using endovascular aortic repair (EVAR) with commercially available devices or open aortic repair (OAR) and reviewed our surgical strategy for AAA.

METHODS

From 1999 to 2019, 1077 patients (659 OAR, 418 EVAR) underwent AAA repair. The OAR and EVAR groups were compared retrospectively, and a propensity matching analysis was performed.

RESULTS

EVAR was first introduced in 2008. Our strategy was changed to an EVAR-first strategy in 2010. Beginning in 2018, this EVAR-first strategy was changed to an OAR-first strategy. After propensity matching, the overall survival in the OAR group was significantly better than that in the EVAR group at 10 years (p = 0.006). Two late deaths due to AAA rupture were identified in the EVAR group, although there were no significant differences between the OAR and EVAR groups with regard to the freedom from AAA-related death at 10 years. The rate of freedom from aortic events at 10 years was significantly higher in the OAR group than in the EVAR group (p < 0.0001).

CONCLUSION

The rates of freedom from AAA-related death in both the OAR and EVAR groups were favorable, and the rate of freedom from aortic events was significantly lower in the EVAR group than in the OAR group. Close long-term follow-up after EVAR is mandatory.

Open Repair of a Large Abdominal Aortic Aneurysm With a Type 2 Endoleak After an Endovascular Aortic Aneurysm Repair: A Case Report and Literature Review

A type 2 endoleak (T2E) can occur after an endovascular aortic aneurysm repair (EVAR). The repair of a T2E is recommended after a sac enlargement of ≥5mm. We present a unique case of a 10 cm aneurysm sac that underwent open explantation 11 years after the initial EVAR and after having undergone several interventions to address the T2E.

Morphological and Clinical Predictors of Early/Follow-up Failure of the Endovascular Infrarenal Abdominal Aneurysm Repair With Currently Available Endografts

PURPOSE

To report outcomes of endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs) with currently-available endografts and identify predictors of technical/clinical failure.

MATERIALS AND METHODS

Patients undergoing EVAR between 2012 and 2020 were prospectively collected and retrospectively analyzed. Technical success (TS: no type I-III endoleaks, renal/hypogastric arteries loss, iliac leg occlusion, conversion to open repair and mortality within 24 postoperative hour), proximal neck-related TS (nr-TS: no proximal type I endoleaks, unplanned renal arteries coverage), and 30-day mortality were assessed as early outcomes. Proximal type I endoleak (ELIa), survival and freedom from reinterventions (FFRs) were assessed during follow-up. Uni/multivariate analysis and Cox-regression were used to identified factors associated with early and follow-up outcomes; FFR and survival were assessed by Kaplan-Meier analysis.

RESULTS

A total of 710 were included. Technical success and nr-TS were 692 (98%) and 700 (99%), respectively. The presence of ≥2 hostile anatomical infrarenal neck characteristics was associated with technical failure (odds ratio [OR]: 2.4; 95% confidence interval [CI]: 1.3-4.1; p: 0.007). Infrarenal neck angle >90° (OR: 2.88; 95% CI: 9.6-50.3; p: 0.004), barrel shape (OR: 2.33; 95% CI: 11.1-100.3; p: 0.02) or presence of ≥2 hostile anatomical infrarenal neck characteristics (OR: 2.16; 95% CI: 2.5-5.3; p: 0.03) were independent risk factors for neck-related technical failures. Six (0.8%) patients died within 30 postoperative days. Chronic obstructive pulmonary disease (OR: 16; 95% CI: 1.1-218.3; p: 0.04) and urgent repair (OR: 15; 95% CI: 1.8-119.6; p: 0.01) were independent risk factors for 30-day mortality. The mean follow-up was 53±13 months. There were 12 (1.7%) ELIa during follow-up. Infrarenal neck length <15 mm (hazard ratio [HR]: 2.8; 95% CI: 1.9-9.6; p: 0.005), diameter >28 mm (HR: 2.7; 95% CI: 1.6-9.5; p: 0.006), angle ≥90° (HR: 2.7; 95% CI: 8.3-50.1; p: 0.007), and persistent type II endoleak (HR: 2.9; 95% CI: 1.6-10.1; p: 0.004) were independent risk factors for ELIa. Freedom from reintervention was 91% at 5 years. The ELIa was an independent risk factor for reinterventions during follow-up (HR: 29.5; 95% CI: 1.4-1.6; p<0.001). Survival was 74% at 5 years with 2 cases (0.3%) of late aortic-related mortality. Peripheral arterial occlusive disease (HR: 1.9; 95% CI: 1.4-3.65; p: 0.03), aneurysm diameter ≥65 mm (HR: 2.2; 95% CI: 1.4-3.26; p<0.001), and infrarenal neck length <15 mm (HR: 1.7; 95% CI: 1.2-2.35; p: 0.04) were independent risk factors for mortality during follow-up.

CONCLUSION

Endovascular repair with currently-available endografts has high TS and low 30-day mortality. Survival and FFRs were satisfactory at mid-term. Pre/postoperative risk factors for technical and clinical failure were identified and they should be considered in EVAR indication and postoperative management to reduce complications and improve mid-term outcome.

CLINICAL IMPACT

Pre and postoperative risk factors for technical and clinical EVAR failure can be identified and they should be considered in EVAR indication and postoperative management to reduce complications and improve mid-term outcome.

Midterm outcomes of aneurysm repair with the COOK Zenith Alpha abdominal endovascular graft

INTRODUCTION

Outcome reports after endovascular aneurysm repair (EVAR) using the low-profile Zenith Alpha Abdominal Endovascular grafts (COOK medical, Bjæverskov, Denmark) are sparse. We present results from a single-center cohort treated with the Zenith Alpha, from a period where the graft was the primary EVAR device choice. The aim of the study was to evaluate short- and midterm outcomes of patients treated with the Zenith Alpha.

METHODS

A retrospective single-center study was performed including all patients treated with the Zenith Alpha graft from October 1, 2015, to September 30, 2018. All patients underwent computed tomography angiography (CTA) imaging preoperatively as well as at three and 12 months postoperatively. Hereafter, patients were followed yearly with duplex ultrasound and clinical exams. Additional imaging was performed on indication. All CTAs were analyzed using three-dimensional reconstruction software (Aquarius, TeraRecon, Durham, NC, USA). Data was extracted from electronic charts according to a protocol that remained unchanged until the end of the study (December 31, 2020). The following outcomes were assessed according to SVS/ISCVS reporting criteria: aortic-related and all-cause mortality, re-interventions, instruction for use (IFU) violations, endoleaks (EL), and aneurysm shrinkage.

RESULTS

A total of 241 patients were treated with the Zenith Alpha, and 214 (89%) were asymptomatic repairs. Technical success was achieved in 238 (99%) patients. 157 (65%) patients received implantation outside IFU. The median hospital length of stay was two days [IQR 2-3 days]. The median clinical follow-up was 35.1 months [IQR 28.8-47.5 months]. The four-year Kaplan-Meier (KM) estimate of freedom from re-intervention was 66% (95% CI: 59-73). The main reasons for re-interventions were iliac limb stenosis and occlusion (n=30; 12%) and type 2 EL (n=13; 5%). Overall, significantly more patients with grafts implanted outside distal IFU developed type 1B ELs (T1BELs) (n=10/11; p=.009). Aneurysm sac shrinkage was observed in 48 (25%) patients one year postoperatively. KM estimates of freedom from aortic-related mortality was 99% (95% CI: 98-100) four years postoperatively.

CONCLUSIONS

EVAR with the Zenith Alpha shows acceptable freedom from aortic-related mortality up to four years postoperatively. The majority of patients were treated outside IFU, and significantly more T1BEL appeared in this subgroup of patients. The leading cause for re-intervention was impaired limb patency. The root cause for impaired limb patency requires further investigation.

Multicentre Outcomes of Redo Fenestrated/Branched Endovascular Aneurysm Repair to Rescue Failed Fenestrated Endografts

OBJECTIVE

To report the outcomes of redo fenestrated and/or branched endovascular aortic repair (F/BEVAR in FEVAR) to rescue previous failed FEVAR.

METHODS

Retrospective review of all consecutive patients undergoing F/BEVAR in FEVAR at eight aortic centres including pre-, intra-, and post-operative data according to a pre-established protocol. Follow up consisted of at least yearly computed tomography angiography. Values are presented as median and interquartile range, and survival as estimate ± standard error in percentage.

RESULTS

18 male patients (76 years old; range 69 - 78 years) receiving FEVAR involving two (two or three) target vessels between 2006 and 2016 underwent F/BEVAR in FEVAR between 2012 and 2019 (aneurysm diameter of 63 mm; range 56 - 69 mm). Median interval between the procedures was 53 (29 - 103) months. The indication for F/BEVAR in FEVAR was type Ia endoleak in 16 cases (eight isolated and eight combined with graft migration), one graft migration without endoleak and one migration with significant proximal aortic expansion. F/BEVAR in FEVAR involved all patent renovisceral arteries and had an operating time of 260 (204 - 344) minutes. Technical success was achieved in 15 (83%) cases. There was a failure to bridge one renal artery, one renal capsular bleed with the subsequent need for renal artery embolisation within 24 hours and one persistent type Ib endoleak despite iliac extension. There was no peri- or in hospital death. Two patients developed spinal cord ischaemia, one transient paraparesis and one permanent paraplegia. The latter occurred in a non-staged procedure where spinal drainage was used. During a follow up of 27 (7 - 39) months, three (17%) patients underwent late re-interventions. Overall survival at 24 months was 70 ± 11% with no aneurysm related death and a secondary clinical success at 24 months of 84 ± 11%.

CONCLUSION

F/BEVAR in FEVAR is a technically challenging but feasible solution to rescue failed FEVAR. The outcomes are promising in many aortic centres but need to be confirmed by further studies with longer follow up.