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Cox K, Yip HCA, Geragotellis A, Al-Tawil M, Jubouri M, Williams IM, Bashir M. Endovascular Solutions for Abdominal Aortic Aneurysms: Fenestrated, Branched and Custom-Made Devices. Vasc Endovascular Surg 2025; 59:64-75. [PMID: 37338859 DOI: 10.1177/15385744231185606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Abdominal aortic aneurysm (AAA) has a prevalence of 4.8%. AAA rupture is associated with significant mortality, thus surgical intervention is generally required once the aneurysm diameter exceeds 5.5 cm. Endovascular aneurysm repair (EVAR) is the predominant repair modality for AAA. However, in patients with complex aortic anatomy, fenestrated or branched EVAR is a superior repair option vs standard EVAR. Fenestrated and branched endoprostheses can be off-the-shelf or custom-made, which offers a more individualised approach. AIM To summarise and evaluate the clinical outcomes achieved by fenestrated EVAR (FEVAR) and branched EVAR (BEVAR), and to explore the role of custom-made endoprostheses in contemporary AAA management. METHODS A literature search using Ovid Medline and Google Scholar was conducted to identify literature pertaining to the use and outcomes of fenestrated, branched, fenestrated-branched and custom-made endoprostheses for AAA repair. RESULTS FEVAR is an effective repair modality for patients with AAA that offers similar early survival, improved early morbidity but higher rates of reintervention in comparison to open surgical repair (OSR). Compared with standard EVAR, FEVAR is associated with similar in-hospital mortality yet higher rates of morbidity, especially regarding renal outcomes. BEVAR outcomes are rarely reported exclusively in the context of AAA repair. When reported, BEVAR is an acceptable alternative to EVAR in the treatment of complex aortic aneurysms and has similar reported complication issues to FEVAR. Custom-made grafts are a good alternative treatment option for complex aneurysms where hostile aneurysm anatomy precludes the use of conventional EVAR and sufficient time is available for the manufacturing of such devices. CONCLUSION FEVAR offers a very effective treatment for patients with complex aortic anatomy and has been well-characterised over the past decade. RCTs and longer-term studies are desirable for unbiased comparison of non-standard EVAR modalities.
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Affiliation(s)
- Kofi Cox
- St. George's University of London, London, UK
| | | | | | | | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Health Education and Improvement Wales (HEIW), Velindre University NHS Trust, Cardiff, UK
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2
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Han JY, James HI, Manesh M, Pyun AJ, Miranda E, Han SM. Hybrid approach to achieve secure distal seal zones during endovascular aortic repair in a patient with Marfan syndrome. J Vasc Surg Cases Innov Tech 2024; 10:101595. [PMID: 39282211 PMCID: PMC11401353 DOI: 10.1016/j.jvscit.2024.101595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 07/22/2024] [Indexed: 09/18/2024] Open
Abstract
This report details a hybrid approach for treatment of abdominal aortic aneurysm in a patient with Marfan syndrome (MFS). A 34-year-old patient with MFS and prior open thoracoabdominal aortic aneurysm repair underwent bilateral common iliac artery interposition graft repair and endovascular aortic repair. The bifurcated stent graft was implanted into the previous thoracoabdominal graft proximally and iliac interposition grafts distally. Postoperatively, the patient recovered uneventfully with sac regression to 4.5 cm through 2-year follow-up, without seal zone degeneration. This hybrid approach aimed to eliminate landing zone degeneration in patients with MFS undergoing endovascular repair.
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Affiliation(s)
- Jesse Y Han
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Herbert I James
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Michelle Manesh
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Alyssa J Pyun
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Elizabeth Miranda
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
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Fujitsuna R, Ueda T, Saito H, Matsumoto T, Shirai S, Sugihara F, Hayashi H, Kumita SI. Initial Outcomes of Embolization for Type II Endoleak: Comparison of n-Butyl Cyanoacrylate-Ethiodized Oil Mixture with n-Butyl Cyanoacrylate-Ethiodized Oil-Ethanol Mixture. J Vasc Interv Radiol 2024; 35:1673-1680. [PMID: 39094848 DOI: 10.1016/j.jvir.2024.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 07/04/2024] [Accepted: 07/24/2024] [Indexed: 08/04/2024] Open
Abstract
PURPOSE To compare the safety and effectiveness of n-butyl cyanoacrylate (nBCA)-ethiodized oil (NE) mixture and nBCA-ethiodized oil-ethanol (NEE) mixture embolization for Type II endoleak (T2EL) after endovascular aortic repair. MATERIALS AND METHODS This study included 32 patients with 49 procedures who underwent T2EL embolization between January 2008 and June 2022. Cases with no follow-up after embolization, technical failure, treatment with coil only, Type I endoleak at the embolization, and re-embolization were excluded. The resultant final cohort included 24 patients (14 men and 10 women; mean age, 83.3 years [interquartile range, 77-89 years]) who underwent initial T2EL embolization, with 15 patients in the NE group and 9 patients in the NEE group. The 2 groups were compared in terms of adverse events (AEs), freedom from sac enlargement, and freedom from reintervention. RESULTS The follow-up period after embolization for T2EL was 960 days (SD ± 1,007) in the NE group and 484 days (SD ± 192) in the NEE group, without significant differences. No AEs above moderate were observed in either group. The rate of freedom from sac enlargement at 1 year was 65.0% in the NE group and 87.5% in the NEE group (P = .03). The rate of freedom from reintervention at 1 year was 69.2% in the NE group and 100.0% in the NEE group (P = .02). CONCLUSIONS The NEE group had significantly higher rates of freedom from sac enlargement and reintervention at 1 year compared with the NE group. These results suggest that T2EL embolization with NEE may be more effective than that with NE.
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Affiliation(s)
- Ryutaro Fujitsuna
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan.
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Hidemasa Saito
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Taiga Matsumoto
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Sayaka Shirai
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Fumie Sugihara
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Hiromitsu Hayashi
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
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Roisin S, Simon S, Adriane M, Thierry R. Retrospective Cohort Study on EVAR Open Surgical Conversion: Focus on Endoleaks With Wrong Preoperative Categorization. Ann Vasc Surg 2024; 108:239-245. [PMID: 38942365 DOI: 10.1016/j.avsg.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/12/2024] [Accepted: 04/21/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Late open conversion (LOC) following endovascular aneurysm repair (EVAR) is a rare complication with a high morbidity and mortality and is often proposed as the last line of treatment after failure of endovascular reintervention of any type. This study aimed to highlights the limitations of EVAR follow-up imaging in characterizing endoleaks, which may contribute to the failure of endovascular reinterventions and lead to LOC. METHODS This retrospective cohort study recruited all EVAR implanted in Amiens University Hospital (France) between January 2008 and December 2022. Elective LOC was defined as surgical conversion >1 month after EVAR. The primary endpoint was the rate of wrong categorization of endoleaks by follow-up exams before LOC. Secondary endpoints were the morbidity and the mortality associated with LOC. RESULTS Seven hundred eight EVARs were performed in our institution, 30 required elective LOC. Twenty-five of them were treated for sac enlargement due to an endoleak (83.3%) (all types). Wrong categorization of the endoleak was noted in 13 patients (52.2%). Twelve of these recategorizations involved the preoperative diagnosis of a type II endoleaks (92.3%). The change in categorization in 7 out of 12 cases (58%) was in favor of a type I endoleak, other recategorization included 1 type III (8%) and 4 type IV (33%). One patient died during the 30-day postoperative period and 7 patients (28%) presented a major complication; the median length of stay was 13 days (interquartile range 9-21). CONCLUSIONS Routine follow-up examinations such as angioscanner and contrast Doppler ultrasound appear to be limited in their ability to categorize the type of persistent endoleak, which may increase the number of patients requiring LOC. New precision diagnostic imaging techniques, such as dynamic examinations, need to be developed to limit the need for LOC.
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Affiliation(s)
- Simon Roisin
- Department of Vascular Surgery, CHU Amiens-Picardie, Amiens, France.
| | - Soudet Simon
- Department of Vascular Medicine, CHU Amiens-Picardie, University Picardie Jules Vernes, Amiens, France
| | - Mage Adriane
- Department of Vascular Surgery, CHU Amiens-Picardie, Amiens, France
| | - Reix Thierry
- Department of Vascular Surgery, CHU Amiens-Picardie, Amiens, France
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5
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Salem O, El Beyrouti H, Mulorz J, Schelzig H, Ibrahim A, Oberhuber A, Dorweiler B. Predictors for reintervention and survival during long-term follow-up after thoracic endovascular aortic repair for descending thoracic aortic aneurysm. J Vasc Surg 2024; 80:1408-1417.e3. [PMID: 39069015 DOI: 10.1016/j.jvs.2024.07.087] [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: 04/06/2024] [Revised: 07/16/2024] [Accepted: 07/21/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Several studies have reported short- and intermediate-term outcomes after thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA); however, reports on long-term (10 years) outcomes are sparse. Therefore, the aim of this study was to analyze predictors impacting long-term outcome after TEVAR for DTAA. METHODS Databases from four academic institutions were reviewed and consecutive cases of TEVAR for DTAA between 1999 and 2021 were included in this retrospective multicenter study (case series). Ethical approval from the institutional review board was obtained and patient demographics and treatment data, as well as follow-up information were retrieved and analyzed. RESULTS We identified 305 patients (mean age, 72 ± 10 years) who were treated with TEVAR for degenerative DTAA with a mean aortic diameter of 64 mm. Altogether 445 endografts were implanted via femoral access (93%) with a technical success of 94%. Operative mortality, stroke rate, and rate of spinal cord ischemia were 6% (5% for intact, 12% for ruptured DTAA), 4%, and 3%, respectively. Kaplan-Meier estimates for overall survival rates were 76%, 59% and 34% at 1, 5 and 10 years and freedom from reintervention rates were 84%, 73% and 58% at 1, 5 and 10 years, respectively. In multivariate analysis, American Society of Anesthesiologists grade 3 to 5 and nonelective case were identified as predictors for death, whereas as fusiform DTAA, proximal landing zone 2, and hypertension, but not device generation, were predictive for reintervention. CONCLUSIONS This study is, to date, the largest reporting long-term (10 years) outcome on TEVAR for DTAA. We found acceptable rates for long-term survival and freedom from reintervention that were independent of endovascular device generation.
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Affiliation(s)
- Oroa Salem
- Department of Vascular and Endovascular Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Hazem El Beyrouti
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz, Mainz, Germany
| | - Joscha Mulorz
- Clinic for Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Hubert Schelzig
- Clinic for Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Heinrich Heine University, Düsseldorf, Germany
| | - Abdelhakim Ibrahim
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Muenster, Germany
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Muenster, Muenster, Germany
| | - Bernhard Dorweiler
- Department of Vascular and Endovascular Surgery, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
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Oderich GS, Huang Y, Harmsen WS, Tenorio ER, Schanzer A, Timaran CH, Schneider DB, Mendes BC, Eagleton MJ, Farber MA, Gasper WJ, Beck AW, Sweet MP, Lee WA. Early and Late Aortic-Related Mortality and Rupture After Fenestrated-Branched Endovascular Aortic Repair of Thoracoabdominal Aortic Aneurysms: A Prospective Multicenter Cohort Study. Circulation 2024; 150:1343-1353. [PMID: 38989575 DOI: 10.1161/circulationaha.123.068234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 06/18/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Fenestrated-branched endovascular aortic repair (FB-EVAR) has been used as a minimally invasive alternative to open surgical repair to treat patients with thoracoabdominal aortic aneurysms (TAAAs). The aim of this study was to evaluate aortic-related mortality (ARM) and aortic aneurysm rupture after FB-EVAR of TAAAs. METHODS Patients enrolled in 8 prospective, nonrandomized, physician-sponsored investigational device exemption studies between 2005 and 2020 who underwent elective FB-EVAR of asymptomatic intact TAAAs were analyzed. Primary end points were ARM, defined as any early mortality (30 days or in hospital) or late mortality from aortic rupture, dissection, organ or limb malperfusion attributable to aortic disease, complications of reinterventions, or aortic rupture. Secondary end points were early major adverse events, TAAA life-altering events (defined as death, permanent spinal cord injury, permanent dialysis, or stroke), all-cause mortality, and secondary interventions. RESULTS A total of 1109 patients were analyzed; 589 (53.1%) had extent I-III and 520 (46.9%) had extent IV TAAAs. Median age was 73.4 years (interquartile range, 68.1-78.3 years); 368 (33.2%) were women. Early mortality was 2.7% (n=30); congestive heart failure was associated with early mortality (odds ratio, 3.30 [95% CI, 1.22-8.02]; P=0.01). Incidence of early aortic rupture was 0.4% (n=4). Incidence of early major adverse events and TAAA life-altering events was 20.4% (n=226) and 7.7% (n=85), respectively. There were 30 late ARMs; 5-year cumulative incidence was 3.8% (95% CI, 2.6%-5.4%); older age and extent I-III TAAAs were independently associated with late ARM (each P<0.05). Fourteen late aortic ruptures occurred; 5-year cumulative incidence was 2.7% (95% CI, 1.2%-4.3%); extent I-III TAAAs were associated with late aortic rupture (hazard ratio, 5.85 [95% CI, 1.31-26.2]; P=0.02). Five-year all-cause mortality was 45.7% (95% CI, 41.7%-49.4%). Five-year cumulative incidence of secondary intervention was 40.3% (95% CI, 35.8%-44.5%). CONCLUSIONS ARM and aortic rupture are uncommon after elective FB-EVAR of asymptomatic intact TAAAs. Half of the ARMs occurred early, and most of the late deaths were not aortic related. Late all-cause mortality rate and the need for secondary interventions were 46% and 40%, respectively, 5 years after FB-EVAR. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02089607, NCT02050113, NCT02266719, NCT02323581, NCT00583817, NCT01654133, NCT00483249, NCT02043691, and NCT01874197.
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Affiliation(s)
- Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, TX (G.S.O., Y.H., E.R.T.)
| | - Ying Huang
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, TX (G.S.O., Y.H., E.R.T.)
| | - William S Harmsen
- Department of Biomedical Statistics and Informatics (W.S.H.), Mayo Clinic, Rochester, MN
| | - Emanuel R Tenorio
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, TX (G.S.O., Y.H., E.R.T.)
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester (A.S.)
| | - Carlos H Timaran
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, TX (G.S.O., Y.H., E.R.T.)
| | - Darren B Schneider
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia (D.B.S.)
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery (B.C.M.), Mayo Clinic, Rochester, MN
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston (M.J.E.)
| | - Mark A Farber
- Division of Vascular Surgery, University of North Carolina, Chapel Hill (M.A.F.)
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, University of California San Francisco (W.J.G.)
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham (A.W.B.)
| | - Matthew P Sweet
- Division of Vascular Surgery, University of Washington, Seattle (M.P.S.)
| | - W Anthony Lee
- Vascular Surgery, Boca Raton Regional Hospital, FL (W.A.L.)
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Kobayashi Y, Ishiguro T, Kagiyama N, Sumi M, Takayanagi N. Prognostic Impact of Pulmonary Diseases in 952 Patients with Thoracic and/or Abdominal Aortic Aneurysm. J Clin Med 2024; 13:6247. [PMID: 39458197 PMCID: PMC11508892 DOI: 10.3390/jcm13206247] [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: 09/29/2024] [Revised: 10/17/2024] [Accepted: 10/17/2024] [Indexed: 10/28/2024] Open
Abstract
Background/Objectives: Pulmonary diseases are common in patients with thoracic aortic aneurysm (TAA) and abdominal aortic aneurysm (AAA). Although high prevalences of chronic obstructive pulmonary disease and lung cancer (LC) are known, the prevalence of these and other pulmonary diseases regarding their relation to the outcome of TAA and/or AAA are not determined. Methods: Pulmonary diseases present at aortic aneurysm (AA) diagnosis and follow-up periods and cause of death of 952 patients with TAA, AAA, or TAA + AAA (including thoracoabdominal AA) treated at our institution in Japan were retrospectively analyzed. Cox regression analysis was used to investigate potential risk factors of mortality. Results: The mean patient age was 72.4 years, and the median follow-up was 4.92 years. At diagnosis, 528 (55.5%) patients had pulmonary diseases, including emphysema without interstitial lung disease (ILD) or LC, LC, idiopathic pulmonary fibrosis (IPF) without LC, non-IPF ILD without LC, and interstitial lung abnormalities (ILAs) without LC in 250, 85, 65, 15, and 58 patients, respectively. During follow-up, LC and acute exacerbation (AE) of IPF developed in 50 and 12 patients, respectively. In 213 patients who died, there were 45 (21.1%) aortic disease-related deaths. Other causes of death included LC (27.7%), cardiovascular events (9.4%), pneumonia (5.6%), and interstitial lung disease (4.7%). In a multivariate Cox regression hazard model, age; larger maximum aneurysm diameter; and coexisting LC, IPF, or concomitant cancer were associated with poor prognosis. Conclusions: In patients with AA, not only age and aneurysm diameter but also coexisting LC and IPF were prognostic factors for mortality.
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Affiliation(s)
- Yoichi Kobayashi
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, 1696 Itai, Kumagaya 360-0197, Saitama, Japan
| | - Takashi Ishiguro
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, 1696 Itai, Kumagaya 360-0197, Saitama, Japan
| | - Naho Kagiyama
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, 1696 Itai, Kumagaya 360-0197, Saitama, Japan
| | - Makoto Sumi
- Department of Vascular Surgery, International University of Health and Welfare, 2600-1 Kita-Kanemaru, Ohtawara 324-8501, Tochigi, Japan
| | - Noboru Takayanagi
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, 1696 Itai, Kumagaya 360-0197, Saitama, Japan
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Bamdé CC, Blitti C, Bar G, Die Loucou J, Laubriet A, Guenancia C, Steinmetz E. PERCUTANEOUS AXILLARY ACCESS IN THE ENDOVASCULAR ERA: A VIABLE ALTERNATIVE? Ann Vasc Surg 2024:S0890-5096(24)00636-8. [PMID: 39419323 DOI: 10.1016/j.avsg.2024.08.029] [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: 07/18/2024] [Revised: 08/21/2024] [Accepted: 08/21/2024] [Indexed: 10/19/2024]
Abstract
BACKGROUND The common femoral artery is the most commonly used vascular access due to its low complication rate and high technical success rate. However, this approach may be less suitable in patients with certain factors such as obesity, the need to treat both lower limbs, and the inability to access the lesion via crossover. In this context, endovascular approaches using percutaneous puncture or upper arm access have emerged. Therefore, we evaluated the feasibility of percutaneous access to the axillary artery in routine endovascular procedures. METHODS This single-center observational study included consecutive patients requiring percutaneous access to the axillary artery for endovascular procedures from January 2020 to December 2023. Demographic and procedural characteristics were collected. The primary endpoint was efficacy (technical success rate) and safety (complications rate) at 30 days. Secondary endpoints were minor complications and risk factors of complications. RESULTS 85 patients were included. Axillary approach was used to treat peripheral artery disease (PAD) in 77.6% (n=66), complex aortic aneurysm in 17.7% (n=15), and acute type B aortic dissection in 4.7% (n=4) of patients. This approach was used due to bilateral PAD treatment (n=20), obesity (n=18), prior EVAR (n=12), prior common femoral artery stenting (n=9), major iliac tortuosity (n=9), prior kissing stent (n=8), favorable angulation (n=5) and true lumen positioning in type B aortic dissection (n=4). The left axillary approach was used in 97.6% (n=83) of cases. The efficacy was 100%. At 30 days, safety was 85.6% with a major complication rate of 14.2% (n=12), including 10.6% (n=9) surgical conversion for hemostasis, 2.4% (n=2) covered stenting, and 1.2% (n=1) stroke. Body mass index was associated with a higher rate of complications (25.2 ± 6.17 vs. 29.0 ± 6.04, OR: 1.2 [1.05; 1.37] p=0.006). CONCLUSION Axillary arteries are an effective alternative access route for patients with unsuitable iliofemoral arteries. Randomized clinical trials are needed to confirm our findings and to assess the best approach for the upper arm.
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Affiliation(s)
- Camil-Cassien Bamdé
- Cardiovascular and thoracic surgery department, Dijon University Hospital, Dijon, France; PEC 2 EA 7460, University of Burgundy and Franche-Comté, Dijon, France.
| | - Comlan Blitti
- Cardiovascular and thoracic surgery department, Dijon University Hospital, Dijon, France
| | - Grégoire Bar
- Cardiovascular and thoracic surgery department, Dijon University Hospital, Dijon, France
| | - Julien Die Loucou
- Cardiovascular and thoracic surgery department, Dijon University Hospital, Dijon, France
| | - Aline Laubriet
- Cardiovascular and thoracic surgery department, Dijon University Hospital, Dijon, France
| | - Charles Guenancia
- PEC 2 EA 7460, University of Burgundy and Franche-Comté, Dijon, France; Cardiology Department, Dijon University Hospital, Dijon, France
| | - Eric Steinmetz
- Cardiovascular and thoracic surgery department, Dijon University Hospital, Dijon, France; PEC 2 EA 7460, University of Burgundy and Franche-Comté, Dijon, France
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Karaolanis GI, Hadjis D, Karakosta A, Bekas N, Tatsis V, Tzimas P, Mitsis M, Peroulis M. Low-Profile Minos TM Stent-Graft System for Endovascular Abdominal Aorta Aneurysm repair. Early and late outcomes in Elective and Emergent situations. Ann Vasc Surg 2024:S0890-5096(24)00621-6. [PMID: 39395585 DOI: 10.1016/j.avsg.2024.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 08/20/2024] [Accepted: 08/21/2024] [Indexed: 10/14/2024]
Abstract
BACKGROUND The aim of the study was to present the results of a novel abdominal stent graft for patients with Abdominal aortic aneurysm (AAA), through 2 years follow-up. METHODS A single-center retrospective review with prospectively collected data was performed to assess the safety and effectiveness of the Minos Abdominal stent device for treating abdominal aortic aneurysms. We estimated technical success rate, in-hospital and 30-day mortality, and mortality at the end of follow-up as well as complication and reintervention rate in our study cohort. Follow-up imaging assessments consisted of computed tomography angiography (CTA) at 1 and 6 months and yearly thereafter. RESULTS A total of 52 patients (92% males; mean age, 74±6 years) were enrolled with Minos Abdominal stent device from July 2020 until September 2023. Thirty one (60%) patients were asymptomatic while 21 (40%) were symptomatic. The technical success of the endovascular aortic repair (EVAR) was 95% (49/52 patients). In 5% (3/52) of the cases, cannulation of the contralateral limb was unsuccessful and was converted to aorto-uni-iliac graft (AIU). Two (4%) aortic related death were recorded during the 30-day period. The major adverse event rate was 3.8%. The overall mean follow-up was 30±6 months; no aorta-related deaths or graft related complications were observed. Sac shrinkage (>5mm) has been observed in 70% of patients. CONCLUSIONS Minos endoprosthesis seems to be safe, effective and durable for treating AAA either in elective or emergent situations.
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Affiliation(s)
- Georgios I Karaolanis
- Vascular Unit, Department of Surgery, University Hospital of Ioannina and School of Medicine, Ioannina, Greece.
| | - Demetrios Hadjis
- Vascular Unit, Department of Surgery, University Hospital of Ioannina and School of Medicine, Ioannina, Greece
| | - Agathi Karakosta
- Department of Anesthesia and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Nikolaos Bekas
- Vascular Unit, Department of Surgery, University Hospital of Ioannina and School of Medicine, Ioannina, Greece
| | - Vassileios Tatsis
- Department of Surgery, School of Health Sciences, University Hospital of Ioannina and Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Petros Tzimas
- Department of Anesthesia and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Michail Mitsis
- Department of Surgery, School of Health Sciences, University Hospital of Ioannina and Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Michail Peroulis
- Vascular Unit, Department of Surgery, University Hospital of Ioannina and School of Medicine, Ioannina, Greece
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Sirignano P, Andreoli F, Gaggiano A, Accarino G, Tusini N, Benedetto F, Veroux P, Silingardi R, Taurino M, Speziale F. Infrarenal Aortic Treatment With AFX2 Endograft: Results From a Multicentric, International, Non-Randomized, Prospective Registry-the AFX2-LIVE Study. J Endovasc Ther 2024:15266028241284364. [PMID: 39369322 DOI: 10.1177/15266028241284364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2024]
Abstract
INTRODUCTION To confirm real-world clinical practice results reported with anatomically fixed bifurcated endograft, a physician-initiated study was designed-AFX2-LIVE registry. MATERIALS AND METHODS From November 2019 to August 2021, investigators enrolled all consecutive patients treated with AFX2 (Endologix Inc., Irvine, CA, USA) endograft. Patients with abdominal aortic aneurysms (AAAs), penetrating aortic ulcers (PAU), and isolated infrarenal aortic dissections were included. Clinical and anatomical data, including baseline, intraoperative, and in-hospital details, as well as follow-up data, were collected in an anonymized prospectively compiled database. The primary endpoint of this study was to evaluate the technical and clinical success of endovascular aortic repair (EVAR) using AFX2 endograft. RESULTS A total of 535 patients were enrolled from 43 Italian and Spanish centers and analyzed according to the protocol. Four hundred eighty-nine patients were male (91.4%), with a mean age of 75±8.92 years (range 52-94). Four hundred sixty-six patients (87.1%) were treated for AAA, 49 (9.3%) for PAU, and 20 (3.6%) for isolated abdominal aortic dissection. A proximal extension was needed in 48% of the cases. Assisted technical success was achieved in all but one patient (99.8%). At 30 days follow-up, no AAA-related deaths were recorded, and nine patients (1.6%) required reintervention. At a mean follow-up period of 15.22±13.65 (range 1-53) months, data were available for 479 patients (89.5%). Clinical success was achieved in 98.2% (95% confidence interval [CI]: 96.4-99.1) at 3 months, 93.9% (95% CI: 90.1-96.1) at 1 year, and 74.1% (95% CI: 62.8-82.4) at 4 years follow-up. The estimated freedom from all-cause mortality was 97.7%, 93.4%, 81.6%, 77.5%, and 70.9%, and freedom from AAA-related mortality was 100%, 99.6%, 99.6%, 99.6%, and 97.3% at 3, 12, 24, 36, and 48 months, respectively. Twenty reinterventions (3.7%) were required in 19 patients, of which 3 late open conversions (0.6%) were performed, and 2 AAA-related deaths were observed. CONCLUSION This study demonstrated excellent clinical and technical success rates of EVAR with anatomically fixed endografts, providing valuable insights into real-world clinical outcomes. CLINICAL IMPACT The AFX2-LIVE study could have a significant impact by providing robust evidence supporting the effectiveness and safety of EVAR using bifurcated endografts with anatomical fixation in real-world clinical practice, ultimately leading to improved outcomes and enhanced patient care in the management of abdominal aortic pathologies.
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Affiliation(s)
- Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Department of General and Specialistic Surgery, Sant'Andrea Hospital of Rome, Sapienza University of Rome, Roma, Italy
| | - Francesco Andreoli
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Gaggiano
- Vascular and Endovascular Surgery, Mauriziano Umberto I Hospital, Torino, Italy
| | - Giancarlo Accarino
- Vascular Surgery, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno, Campania, Italy
| | - Nicola Tusini
- Vascular Surgery, Arcispedale S Maria Nuova, Reggio Emilia, Italy
| | - Filippo Benedetto
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G Martino, University of Messina, Messina, Italy
| | - Pierfrancesco Veroux
- Vascular Surgery and Organ Transplant Unit, Azienda Policlinico San Marco, University of Catania, Catania, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Maurizio Taurino
- Vascular and Endovascular Surgery Unit, Department of General and Specialistic Surgery, Sant'Andrea Hospital of Rome, Sapienza University of Rome, Roma, Italy
| | - Francesco Speziale
- Vascular and Endovascular Surgery Unit, Department of General and Specialistic Surgery, Policlinico Umberto I Hospital of Rome, Sapienza University of Rome, Roma, Italy
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Vázquez Pérez R, Álvarez Marcos F, Tello Díaz C, Bellmunt Montoya S, Fernández-Samos Gutiérrez R, Gil Sala D. Psoas muscle analysis as a surrogate marker of sarcopenia and frailty: A multicenter analysis of predictive capacities over short- and long-term outcomes after abdominal aortic aneurysm repair. Vascular 2024; 32:973-982. [PMID: 37526918 DOI: 10.1177/17085381231193453] [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: 08/02/2023]
Abstract
OBJECTIVES Several predictive models exist for estimating the postoperative risks of abdominal aortic aneurysm (AAA) repair, although no particular tool has seen widespread use. We present the results of a multicenter, historic cohort study comparing the predictive capacity of the psoas muscle area (PMA), radiodensity (PMD), and lean muscle area (LMA) as surrogate markers of sarcopenia, over short- and long-term outcomes after AAA repair, compared to the mFI-5 and American Society of Anesthesiologists (ASA) scales. METHODS Retrospective review was conducted of all consecutive AAA elective repair cases (open or endovascular) in three tertiary-care centers from 2014 to 2019. Cross-sectional PMA, PMD, and LMA at the mid-body of the L3 vertebra were measured by two independent operators in the preoperative computed tomography. Receiver operating characteristic (ROC) curves were used to determine optimal cutoff values. Bivariate analysis, logistic regression, and Cox's proportional hazards models were built to examine the relationship between baseline variables and postoperative mortality, long-term mortality, and complications. RESULTS 596 patients were included (mean age 72.7 ± 8 years, 95.1% male, 66.9% EVAR). Perioperative mortality was 2.3% (EVAR 1.2% vs open repair 4.6%, p = .015), and no independent predictors could be identified in the multivariate analysis. Conversely, an age over 74 years old (OR 1.84 95%CI 1.25-2.70), previous heart diseases (OR 1.62 95%CI 1.13-2.32), diabetes mellitus (OR 1.61 95%CI 1.13-2.32), and a PMD value over 66 HU (OR 0.58 95%CI 0.39-0.84) acted as independent predictors of long-term mortality in the Cox's proportional hazards model. Heart diseases (congestive heart failure or coronary artery disease), serum creatinine levels over 1.05 mg/dL, and an aneurysm diameter over 60 mm were independent predictors of major complications. CONCLUSION Surrogate markers of sarcopenia had a poor predictive profile for postoperative mortality after AAA repair in our sample. However, PMD stood out as an independent predictor of long-term mortality. This finding can guide future research and should be confirmed in larger datasets.
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Affiliation(s)
- Rocío Vázquez Pérez
- Angiology and Vascular Surgery Department, Hospital Universitario de Canarias, La Laguna, Spain
| | - Francisco Álvarez Marcos
- Angiology and Vascular Surgery Department, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Cristina Tello Díaz
- Angiology and Vascular Surgery Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Sergi Bellmunt Montoya
- Angiology and Vascular Surgery Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Daniel Gil Sala
- Angiology and Vascular Surgery Department, Hospital Clínic de Barcelona, Barcelona, Spain
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Asha A, Khan A, Joshi G, El Khoury R, Jacobs CE, Schwartz LB, Marinov M. Delayed abdominal aortic aneurysm sac rupture after open repair. J Vasc Surg Cases Innov Tech 2024; 10:101552. [PMID: 39281287 PMCID: PMC11400978 DOI: 10.1016/j.jvscit.2024.101552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 05/26/2024] [Indexed: 09/18/2024] Open
Abstract
Open surgical repair of abdominal aortic aneurysm (AAA) is often regarded as a near-permanent operation with little long-term complications. Reported herein is a case of delayed rupture of an enlarging AAA sac after open repair requiring re-exploration in a patient presenting with flank pain and ipsilateral hydronephrosis. The natural history of a large, excluded aneurysm sac after open AAA repair, hypothesized etiology for this rare occurrence, and proposed diagnostic and therapeutic algorithm are described.
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Affiliation(s)
- Ahmad Asha
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Adnan Khan
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Gaurang Joshi
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Rym El Khoury
- Department of Surgery, Division of Vascular Surgery, NorthShore University Health System, Evanston, IL
| | - Chad E Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Marin Marinov
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
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Kamisako A, Nakai M, Saguchi T, Tanaka T, Okada Y, Ishida M, Saito K. The usefulness of contrast-enhanced subtraction magnetic resonance imaging for detecting endoleaks after endovascular aortic repair with prophylactic intraoperative sac embolization. Acta Radiol 2024; 65:1205-1210. [PMID: 39091041 DOI: 10.1177/02841851241263987] [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: 08/04/2024]
Abstract
BACKGROUND Metallic and hyperdense artifacts and T1-shortening substances in the abdominal aortic aneurysm (AAA) sac generated by embolic materials and lipiodol pose challenges in the identification of endoleaks on follow-up computed tomography (CT) or magnetic resonance imaging (MRI). PURPOSE To evaluate the usefulness of contrast-enhanced subtraction MRI (CES-MRI) for detecting endoleaks after endovascular abdominal aortic aneurysm repair (EVAR) with intraoperative AAA sac embolization compared with CE-CT, this study was conducted. MATERIAL AND METHODS In this study, 28 consecutive patients who underwent EVAR with prophylactic AAA sac embolization were included. All patients underwent CES-MRI and CE-CT to detect endoleaks. The definitive diagnosis of endoleaks was a consensus reading of CE-CT and CES-MRI by two certified radiologists, in addition to angiography or reproducible radiological findings in the observational examination. Analysis was performed to evaluate which examination was better for detecting endoleaks. RESULTS The sensitivity, specificity, and area under the curve of CE-CT and CES-MRI according to observer 1 were 50%, 100%, and 0.813 (95% confidence interval [CI] = 0.625-1.00) and 100%, 95%, and 0.997 (95% CI = 0.984-1.00), respectively, and those according to observer 2 were 50%, 100%, and 0.750 (95% CI = 0.514-0.986) and 100%, 95%, and 0.969 (95% CI = 0.903-1.00), respectively. Intolerable artifacts were significantly observed on CE-CT. The severity of the artifacts did not depend on the stent graft on CT and MRI. CONCLUSION Although no significant difference was observed, CES-MRI tended to have better accuracy for endoleak detection in EVAR with intraoperative AAA sac embolization than CE-CT.
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Affiliation(s)
- Atsufumi Kamisako
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama, Japan
| | - Motoki Nakai
- Department of Radiology, Tokyo Medical University, Shinjyukuku, Tokyo, Japan
| | - Toru Saguchi
- Department of Radiology, Tokyo Medical University, Shinjyukuku, Tokyo, Japan
| | - Taro Tanaka
- Department of Radiology, Tokyo Medical University, Shinjyukuku, Tokyo, Japan
| | - Yukinori Okada
- Department of Radiology, Tokyo Medical University, Shinjyukuku, Tokyo, Japan
| | - Masanori Ishida
- Department of Radiology, Tokyo Medical University, Shinjyukuku, Tokyo, Japan
| | - Kazuhiro Saito
- Department of Radiology, Tokyo Medical University, Shinjyukuku, Tokyo, Japan
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Antonello M, Bilato MJ, Menara S, Grego F, Piazza M, Squizzato F. Carbon dioxide cone-beam computed tomography for the technical assessment of endovascular aortic intervention. J Vasc Surg Cases Innov Tech 2024; 10:101580. [PMID: 39234560 PMCID: PMC11372803 DOI: 10.1016/j.jvscit.2024.101580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 07/02/2024] [Indexed: 09/06/2024] Open
Abstract
Cone-beam computed tomography (CBCT) is widely used for the technical assessment of standard and complex endovascular aortic interventions. Use of iodinated contrast in CBCT imaging might provide useful additional information; however, this also increases the procedural contrast dose, which may cause renal function deterioration, and the radiation exposure. We describe the technique and feasibility of carbon-dioxide (CO2)-enhanced CBCT for the technical assessment of standard and complex endovascular aortic repair. In our experience CO2-CBCT had no related adverse events and provided satisfactory imaging quality to assess endograft integrity, vessels patency, and was safely performed in case of severe chronic renal insufficiency.
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Affiliation(s)
- Michele Antonello
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University, Padova, Italy
| | - Marco James Bilato
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University, Padova, Italy
| | - Sabrina Menara
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University, Padova, Italy
| | - Franco Grego
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University, Padova, Italy
| | - Michele Piazza
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University, Padova, Italy
| | - Francesco Squizzato
- Vascular and Endovascular Surgery Division, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University, Padova, Italy
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15
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Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024; 45:3538-3700. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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16
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Choi E, Kwon TW. Endovascular Treatment versus Open Surgical Repair for Isolated Iliac Artery Aneurysms. Vasc Specialist Int 2024; 40:31. [PMID: 39328043 PMCID: PMC11437323 DOI: 10.5758/vsi.240041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/27/2024] [Accepted: 07/16/2024] [Indexed: 09/28/2024] Open
Abstract
Purpose Endovascular treatment (EVT) has been shown to be effective and safe for isolated iliac artery aneurysms (IAAs). However, concerns remain regarding the lack of consideration to recent advances in perioperative care and surgical techniques, as well as a significant number of re-interventions with EVT. This study compares the outcomes of open surgical repair (OSR) and EVT using recent clinical data. Materials and Methods This retrospective, single-center study included patients who underwent OSR or EVT for isolated degenerative IAAs between January 2007 and December 2018. Primary outcomes were procedure time, number of transfusions during admission, length of hospital stay, complications, and number of preserved internal iliac arteries. Secondary outcomes included all-cause and aneurysm-related mortality, and re-intervention rates. Results Fifty-eight consecutive patients underwent treatment for isolated IAAs (25 underwent OSR and 33 underwent EVT), with a median follow-up of 75 months (range: 39-133 months). Baseline characteristics were similar between the groups, except for a lower mean age in the OSR group than in the EVT group (66.0±8.2 vs. 73.1±8.6, P=0.003). Both groups had a mild risk of comorbidity severity score. Early complications (within 30 days of the procedure) occurred more frequently in the OSR group, though not statistically significant (24.0% vs. 6.1%, P=0.07). Late complications, including sac expansion and thrombotic occlusion, were significantly more common in the EVT group (15.2% vs. 0%, P=0.04). Re-intervention rate was higher in the EVT group but not statistically significant (9.1% vs. 4.0%, P=0.44). No significant differences were observed in major adverse cardiovascular events and mortality between the groups (P=0.66 and P=0.27), and there were no aneurysm-related deaths. Conclusion For patients with mild risk factors, EVT does not offer a survival or re-intervention advantages over OSR in the treatment of isolated IAAs. However, EVT is associated with an increased risk of late complications. Although larger randomized studies are necessary, OSR may be considered the first-line treatment for isolated IAAs in younger and mild-risk patients.
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Affiliation(s)
- Eol Choi
- Division of Vascular Surgery, Department of Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Tae Won Kwon
- Division of Trauma Surgery, Department of Surgery, Korea University Guro Hospital, Seoul, Korea
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17
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Manunga J, Hanif H, Cravero E, Goldman J, Clark RM, Skeik N, Stephenson E, Harris KM, Rana MA. Midterm Outcomes of Patients With Complex Aortic Aneurysms Treated Using Mixed and Matched Endoprosthesis From Different Manufacturers. J Endovasc Ther 2024:15266028241283252. [PMID: 39323323 DOI: 10.1177/15266028241283252] [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: 09/27/2024]
Abstract
OBJECTIVES To evaluate outcomes of patients with complex aortic aneurysms (cAAs) undergoing fenestrated/branched endovascular aortic aneurysm repair (f/b-EVAR) using a combination of endoprostheses from different manufacturers. METHODS The study is a 2-center retrospective analysis of prospectively maintained databases of patients with cAAs undergoing f/b-EVAR using a combination of endoprostheses from different manufacturers from 2013 to 2023. Primary endpoints included technical success, major adverse events and reintervention rates. Technical success was defined as implantation of the device without type I or type III endoleak or conversion to open repair. Secondary endpoints included mortality and mid-term device performance. RESULTS During this time, 353 patients with cAAs underwent f/b-EVARs at both centers. Of these, 80 (22.7%) required use of a combination of devices from 4 different manufacturers for repair. Fifty-one (64%) were treated for thoracoabdominal aortic aneurysms and 29 (36%) for pararenal aneurysms. Majority (74%) were male with a median age of 75 (69, 81) years and aneurysm size of 65 (59, 72) mm. Thirty-five (44%) patients required a proximal thoracic stent graft-W.L. Gore (17), Cook, Medtronic, and Terumo (6), respectively. Seventy-seven (96%) patients required a bifurcated device, including Cook Flex (34), Gore (40), and Medtronic (3). Twelve patients underwent common iliac artery aneurysm repair with a Gore iliac branched endoprosthesis. One hundred fifty-four limbs were implanted: Gore: 68, Cook: 82 and Medtronic: 4. Three hundred fourteen target vessels were incorporated. Median operating room time, estimated blood loss, fluoroscopy time and dose were 209 (186, 278) minutes, 100 (50, 663) mL, 77 (59, 100) minutes, 2385 (1415, 3885) mGy, respectively. Three endoleaks were observed on completion angiography-2 type Ic and 1 type IIIa-all of which resolved at 1 month. Fifteen MAEs were observed in 11 patients at 30 days, including 3 (3.9%) deaths, 7 renal insufficiency, 1 renal failure requiring dialysis, 2 MI and paraplegia, respectively. At a median follow-up of 400 (85, 1132) days, there were 8 reinterventions for endoleaks in 7 patients. CONCLUSIONS The use of mixed devices proximal and distal to f/b-devices built to treat patients with cAAs is safe and has good mid-term results. CLINICAL IMPACT While not yet formally assessed in randomized clinical trials or endorsed by the Food and Drug Administration (FDA), the practice of utilizing devices from various manufacturers to address complex aortic anatomy is widespread in everyday clinical settings, yet outcomes remain insufficiently documented. To our knowledge, ours is the first manuscript demonstrating that the use of endoprostheses from different manufacturers for treating patients with complex aortic aneurysms is both safe and yields favorable mid-term results. This frequently employed strategy warrants further exploration through meticulously designed clinical trials, aiming to furnish vascular specialists with a well-founded guideline based on robust clinical evidence.
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Affiliation(s)
- Jesse Manunga
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
- Minneapolis Heat Institute Foundation, Minneapolis, MN, USA
| | - Hamza Hanif
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Ellen Cravero
- Minneapolis Heat Institute Foundation, Minneapolis, MN, USA
| | - JoAnn Goldman
- Minneapolis Heat Institute Foundation, Minneapolis, MN, USA
| | - Ross M Clark
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Nedaa Skeik
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
- Minneapolis Heat Institute Foundation, Minneapolis, MN, USA
| | - Elliot Stephenson
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
- Minneapolis Heat Institute Foundation, Minneapolis, MN, USA
| | - Kevin M Harris
- Minneapolis Heat Institute Foundation, Minneapolis, MN, USA
- Section of Cardiology, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Muhammad Ali Rana
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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18
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Allievi S, Caron E, Rastogi V, Yadavalli SD, Jabbour G, Mandigers TJ, O'Donnell TFX, Patel VI, Torella F, Verhagen HJM, Trimarchi S, Schermerhorn ML. Retroperitoneal vs transperitoneal approach for nonruptured open conversion after endovascular aneurysm repair. J Vasc Surg 2024:S0741-5214(24)01888-3. [PMID: 39299528 DOI: 10.1016/j.jvs.2024.09.009] [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: 02/17/2024] [Revised: 09/04/2024] [Accepted: 09/11/2024] [Indexed: 09/22/2024]
Abstract
OBJECTIVE Several studies comparing the transperitoneal (TP) and retroperitoneal (RP) approach for abdominal aortic aneurysm (AAA) repair suggest that the RP approach may result in lower rates of perioperative mortality and morbidity. However, data comparing these approaches for open conversion are lacking. This study aims to evaluate the association between the type of approach and outcomes following open conversion after endovascular aneurysm repair (EVAR). METHODS We included all patients who underwent open conversion after EVAR between 2010 and 2022 in the Vascular Quality Initiative. Patients presenting with rupture were excluded. The primary outcome was perioperative mortality. The secondary outcomes included perioperative complications and 5-year mortality. Inverse probability weighting was used to adjust for factors with statistical or clinical significance. Logistic regression was used to assess perioperative mortality and complications in the weighted cohort. The 5-year mortality was evaluated using Kaplan-Meier and Cox regression. RESULTS We identified 660 patients (39% RP) who underwent open conversion after EVAR. Compared with TP, RP patients were older (75 years [interquartile range, 70-79 years] vs 73.5 years [interquartile range, 68-79 years]; P < .001), and more frequently had prior myocardial infarction (33% vs 22%; P = .002). Compared with the TP approach, the RP approach was used less frequently in cases of associated iliac aneurysm (19% vs 27%; P = .026), but more frequently with associated renal bypass (7.8% vs 1.7%; P < .001) and by high-volume physicians (highest quintile, >7 AAA annually: 41% vs 17%; P < .001) and in high-volume centers (highest quintile, >35 AAA annually: 36% vs 20%; P < .001). RP patients, compared with TP patients, were less likely to have external iliac or femoral distal anastomosis (8.2% vs 21%; P < .001), and an infrarenal clamp (25% vs 36%; P < .001). Unadjusted perioperative mortality was not significantly different between approaches (RP vs TP: 3.8% vs 7.5%; P = .077). After risk adjustment, RP patients had similar odds of perioperative mortality (adjusted odds ratio [aOR], 0.49; 95% confidence interval [CI], 0.22-1.10; P = .082), and lower odds of intestinal ischemia (aOR, 0.26; 95% CI, 0.08-0.86; P = .028) and in-hospital reintervention (aOR, 0.43; 95% CI, 0.22-0.85; P = .015). No significant differences were found in the other perioperative complications or 5-year mortality (aHR, 0.79; 95% CI, 0.47-1.32; P = .37). CONCLUSIONS Our findings suggest that the RP approach may be associated with a lower adjusted odds of perioperative complications compared with the TP approach. The RP approach should be considered for open conversion after EVAR when feasible.
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Affiliation(s)
- Sara Allievi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Caron
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gabriel Jabbour
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Tim J Mandigers
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Interventions, New York Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Virendra I Patel
- Division of Vascular and Endovascular Interventions, New York Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Francesco Torella
- Liverpool Vascular and Endovascular Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK; School of Physical Sciences, University of Liverpool, Liverpool, UK; Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Santi Trimarchi
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Aljabri B, Iqbal K, Alanezi T, Al-Salman M, Altuwaijri T, Aldossary MY, Alarify GA, Alhadlaq LS, Alhamlan SA, AlSheikh S, Altoijry A. Thoracic Endovascular Aortic Repair and Endovascular Aneurysm Repair Approaches for Managing Aortic Pathologies: A Retrospective Cohort Study. J Clin Med 2024; 13:5450. [PMID: 39336937 PMCID: PMC11432449 DOI: 10.3390/jcm13185450] [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: 07/14/2024] [Revised: 08/28/2024] [Accepted: 09/11/2024] [Indexed: 09/30/2024] Open
Abstract
Background/Objectives: Since thoracic endovascular aortic repair (TEVAR) and endovascular aneurysm repair (EVAR) are increasingly utilized, examining their outcomes and safety in real-world scenarios is crucial. This study investigated the management and outcomes of TEVAR and EVAR as alternatives to traditional open surgical repair for managing aortic pathologies. Methods: This was a retrospective cohort study. We analyzed the data from 59 consecutive patients who underwent TEVAR or EVAR between 2015 and 2022 at a single tertiary care center. The primary outcome was survival, and secondary outcomes were complications assessment, including re-intervention and occurrence of endoleaks. Results: TEVAR accounted for 47.5% of cases (n = 28), while EVAR comprised 52.5% (n = 31). Patients were mostly 61-70 years old (23.7%) and male (91.5%). Surgery indications differed, with aneurysmal repair being the prevalent indication for EVAR (90.3%, n = 28) and trauma being the main indication for TEVAR (67.9%, n = 19). Regarding the primary outcome, 11 patients (18.6%) died for various reasons; of those, 2 patients (3.4%) were determined to have died from vascular-related issues. Most patients (81.4%, n = 48) did not experience intraoperative complications. The most common intraoperative complications were endoleaks and access failure, each affecting 5.1% (n = 3) of patients. Re-intervention was necessary in 16.9% (n = 10) of cases, with endoleaks being the major indication (60%). Emergency intervention was more frequent in the TEVAR group (p = 0.013), resulting in significantly longer hospitalization (p = 0.012). Conclusions: Despite limitations, our analysis indicates a good safety profile with high success rates and a low incidence of adverse health outcomes and mortality in TEVAR/EVAR procedures. Nevertheless, the results emphasize the ongoing concern of endograft leaks, necessitating re-interventions.
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Affiliation(s)
- Badr Aljabri
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
| | - Kaisor Iqbal
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
| | - Tariq Alanezi
- College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
| | - Mussaad Al-Salman
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
| | - Talal Altuwaijri
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
| | - Mohammed Yousef Aldossary
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
- Division of Vascular Surgery, Department of Surgery, Dammam Medical Complex, Dammam 32245, Saudi Arabia
| | - Ghadah A Alarify
- College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
| | - Leen S Alhadlaq
- College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
| | - Sarah A Alhamlan
- College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
| | - Sultan AlSheikh
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
| | - Abdulmajeed Altoijry
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia
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20
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Sandström C, Andersson MB, Bogdanovic M, Fattahi N, Lundqvist R, Andersson M, Roy J, Hultgren R, Roos H. Sealing Zone Failure Decreases the Long Term Durability of Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00800-1. [PMID: 39251037 DOI: 10.1016/j.ejvs.2024.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 08/16/2024] [Accepted: 09/04/2024] [Indexed: 09/11/2024]
Abstract
OBJECTIVE Endovascular aneurysm repair (EVAR) has a higher long term aneurysm related mortality rate compared with open surgery, mainly due to aneurysm rupture. Loss of stent graft to vessel apposition at the EVAR sealing zones is a potential cause of post-EVAR rupture. This study aimed to investigate sealing zone failure and its relationship with post-EVAR rupture. METHODS This was a retrospective structured review of pre- and post-operative computed tomography (CT) scans of 399 consecutive patients treated with standard bifurcated EVAR. The primary outcome was total loss of seal at last post-operative CT. Secondary outcomes were partial loss of seal, standard follow up detection, post-EVAR rupture, aneurysm sac development, and endoleaks. RESULTS During a median follow up of 5.3 years, total and partial loss of seal occurred in 85 (21.3%) and 78 (19.5%) patients, respectively. Initial mean sealing zone lengths were within current recommendations but decreased over time, mainly due to vessel dilatation. Mean proximal sealing length at the one month CT was 15.5 ± 10.5 mm (95% confidence interval [CI] 12.6 - 18.5 mm) in the group with total loss of seal, 14.3 ± 6.9 mm (95% CI 12.2 - 16.4 mm) with partial loss of seal, and 23.2 ± 7.4 mm (95% CI 22.3 - 24.0 mm) with preserved seal through follow up (p < .001). Mean iliac sealing lengths were 22.4 ± 12.1 mm (95% CI 18.9 - 25.8 mm) if total loss and 21.8 ± 10.0 mm (95% CI 19.6 - 24.0 mm) if partial loss of seal vs. 34.7 ± 12.4 mm (95% CI 33.8 - 35.7 mm) if preserved seal. Larger vessel diameters were associated with loss of seal in both the proximal and distal sealing zones. During the study period, 13 post-EVAR ruptures occurred, all preceded by CT findings of total (n = 7) or partial (n = 6) loss of seal. Aneurysm sac expansion was seen in 40% of patients with total loss of seal, 18% with partial loss of seal, and 6.6% with preserved seal. CONCLUSION Loss of seal after EVAR is frequent and associated with post-EVAR rupture. Increased recommended sealing zones lengths and focus on sealing zones in surveillance may reduce post-EVAR ruptures and aneurysm related death.
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Affiliation(s)
- Charlotte Sandström
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mattias B Andersson
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sunderbyn Hospital, Sunderbyn, Sweden
| | - Marko Bogdanovic
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Nina Fattahi
- Department of Clinical Science and Education, Karolinska Institutet at Södersjukhuset, Stockholm, Sweden; Section of Vascular Surgery, Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Robert Lundqvist
- Department of Public Health and Clinical Medicine, Umeå University, Norrbotten County Council, Sweden
| | - Manne Andersson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Surgery, Ryhov Hospital, Jönköping, Sweden
| | - Joy Roy
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Rebecka Hultgren
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Roos
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Ryhov Hospital, Jönköping, Sweden.
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21
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Maze Y, Tokui T, Inoue R, Sekoguchi T, Narukawa T, Murakami M, Inoue R, Hirano K, Chino S, Nakajima K, Kato N, Ito H. The outcomes and cost analysis of open repair and endovascular aneurysm repair for abdominal aortic aneurysms: a single-center experience in Japan. Surg Today 2024:10.1007/s00595-024-02934-7. [PMID: 39227396 DOI: 10.1007/s00595-024-02934-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 08/17/2024] [Indexed: 09/05/2024]
Abstract
PURPOSE Japan has adopted its own reimbursement system, which differs from other countries in terms of its diagnostic procedure combination (DPC) methods. However, there are few reports on the cost analysis of open repair and endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms in Japan. We aimed to evaluate the long-term outcomes and cost-effectiveness of these two procedures. METHODS This study included patients who underwent open repair (n = 224) and EVAR (n = 87) between January 2012 and December 2022. After propensity score matching, we compared the two groups. RESULTS The drug and blood products, procedures, and DPC costs were significantly higher in the open repair group (p < 0.001) than in the EVAR group. The surgical equipment and total costs were significantly higher in the EVAR group than in the open repair group (p < 0.001). There was no significant difference in the 5-year survival rate (88.5% in the open repair group vs. 72.0% in the EVAR group; p = 0.33) and freedom from re-intervention rate at 5 years (93.1% in the open repair group vs. 89.9% in the EVAR group; p = 0.15) between the two groups. CONCLUSIONS Open repair is more cost-effective than EVAR. The cost-effectiveness of EVAR may therefore depend on the cost of the endograft.
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Affiliation(s)
- Yasumi Maze
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan.
| | - Toshiya Tokui
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan
| | - Ryotaro Inoue
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan
| | - Tomotake Sekoguchi
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan
| | - Takahiro Narukawa
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan
| | - Masahiko Murakami
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan
| | - Ryosai Inoue
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan
| | - Koji Hirano
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan
| | - Shuji Chino
- Department of Radiology, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan
| | - Ken Nakajima
- Department of Radiology, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan
| | - Noriyuki Kato
- Department of Radiology, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan
| | - Hisato Ito
- Department of Thoracic and Cardiovascular Surgery, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-0001, Japan
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Yang Q, Hu J, Luo Y, Jia D, Chen N, Yao C, Wu R. Detection of Endoleak after Endovascular Aortic Repair through Deep Learning Based on Non-contrast CT. Cardiovasc Intervent Radiol 2024; 47:1267-1275. [PMID: 38977447 DOI: 10.1007/s00270-024-03805-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Accepted: 06/25/2024] [Indexed: 07/10/2024]
Abstract
OBJECTIVES To develop and validate a deep learning model for detecting post-endovascular aortic repair (EVAR) endoleak from non-contrast CT. METHODS This retrospective study involved 245 patients who underwent EVAR between September 2016 and December 2022. All patients underwent both non-enhanced and enhanced follow-up CT. The presence of endoleak was evaluated based on computed tomography angiography (CTA) and radiology reports. First, the aneurysm sac was segmented, and radiomic features were extracted on non-contrast CT. Statistical analysis was conducted to investigate differences in shape and density characteristics between aneurysm sacs with and without endoleak. Subsequently, a deep learning model was trained to generate predicted segmentation of the endoleak. A binary decision was made based on whether the model produced a segmentation to detect the presence of endoleak. The absence of a predicted segmentation indicated no endoleak, while the presence of a predicted segmentation indicated endoleak. Finally, the performance of the model was evaluated by comparing the predicted segmentation with the reference segmentation obtained from CTA. Model performance was assessed using metrics such as dice similarity coefficient, sensitivity, specificity, and the area under the curve (AUC). RESULTS This study finally included 85 patients with endoleak and 82 patients without endoleak. Compared to patients without endoleak, patients with endoleak had higher CT values and greater dispersion. The AUC in validation group was 0.951, dice similarity coefficient was 0.814, sensitivity was 0.877, and specificity was 0.884. CONCLUSION This deep learning model based on non-contrast CT can detect endoleak after EVAR with high sensitivity.
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Affiliation(s)
- Qingqi Yang
- Department of Vascular Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jinglang Hu
- School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Yingqi Luo
- Department of Medical Imaging, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Dongdong Jia
- Department of Vascular Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Nuo Chen
- Department of Vascular Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Chen Yao
- Department of Vascular Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ridong Wu
- Department of Vascular Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
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Hohri Y, Kawajiri H, Kanda K, Numata S, Kobayashi T, Nakai R, Yaku H. Side-by-side deployment of gore excluder legs at a narrow terminal aorta for endovascular aneurysm repair. J Artif Organs 2024; 27:238-246. [PMID: 37227546 DOI: 10.1007/s10047-023-01406-y] [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: 12/16/2022] [Accepted: 05/16/2023] [Indexed: 05/26/2023]
Abstract
PURPOSE A narrow terminal aorta is a risk factor for endograft occlusion after endovascular aneurysm repair. To minimize limb complications, we used Gore Excluder legs positioned side-by-side at the terminal aorta. We investigated the outcomes of our strategy for endovascular aneurysm repair in patients with a narrow terminal aorta. METHODS We enrolled 61 patients who underwent endovascular aneurysm repair with a narrow terminal aorta (defined as < 18 mm in diameter) from April 2013 to October 2021. The standard procedure involves complete treatment with the Gore Excluder device. When other types of main body endografts were used, they were deployed proximal to the terminal aorta, and we used the Gore Excluder leg device in the bilateral limbs. Postoperatively, the intraluminal diameter of the legs at the terminal aorta was measured to assess the configuration. RESULTS During the follow-up period (mean: 2.7 ± 2.0 years), there were no aorta-related deaths, endograft occlusions, or leg-related re-interventions. There were no significant differences between the pre- and postoperative ankle-brachial pressure index values in the dominant and non-dominant legs (p = 0.44 and p = 0.17, respectively). Postoperatively, the mean difference rate (defined as [dominant leg diameter-non-dominant leg diameter]/terminal aorta diameter) was 7.5 ± 7.1%. The difference rate was not significantly correlated with the terminal aortic diameter, calcification thickness, or circumferential calcification (r = 0.16, p = 0.22; r = 0.07, p = 0.59; and r = - 0.07, p = 0.61, respectively). CONCLUSIONS Side-by-side deployment of Gore Excluder legs produces acceptable outcomes for endovascular aneurysm repair with a narrow terminal aorta. The endograft expansion at the terminal aorta is tolerable without influencing calcification distribution.
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Affiliation(s)
- Yu Hohri
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachi Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan.
| | - Hidetake Kawajiri
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachi Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan.
| | - Keiichi Kanda
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachi Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachi Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Takuma Kobayashi
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachi Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Rie Nakai
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachi Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-Cho, Kawaramachi Hirokoji, Kamigyo-Ku, Kyoto, 602-8566, Japan
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24
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Zhang Y, Ji Y, Wu G, Zhang M, Li X, Zhou M. Surgical Treatment for Sac Expansion Caused by Type II Endoleaks after Endovascular Aneurysm Repair of Abdominal Aortic Aneurysms/Iliac Aneurysms. Ann Vasc Surg 2024; 106:479-487. [PMID: 38615753 DOI: 10.1016/j.avsg.2024.01.023] [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: 11/21/2023] [Revised: 01/12/2024] [Accepted: 01/28/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND This study aimed to examine the outcomes of open surgery techniques involving sacotomy and suturing of the feeding vessels in patients with aneurysm sac expansion after endovascular aneurysm repair (EVAR). METHODS Fourteen consecutive patients treated with sacotomy and suturing of feeding vessels for expanding aneurysm sacs with type II endoleaks following EVAR, between January 2018 and December 2022, were retrospectively included. All patients underwent preoperative digital subtraction angiography, and attempts were made to embolize the thick feeding vessels to reduce intraoperative bleeding. Age, sex, comorbidities, clinical presentation, aneurysm sac increase, morbidity, mortality, and follow-up were recorded. RESULTS The median age of the patients was 72.89 ± 5.13 years old, and 13 (92.9%) patients were male. The sac size at the time of the open procedure was 107.89 ± 22.58 mm, and the extent of sac growth at the time of the open procedure was 37.50 ± 18.29 mm. The initial technical success rate of laparotomy and open ligation of the culprit arteries causing type II endoleaks was 92.9% (13/14). Among the patients, 5 (35.7%) had been treated with interventional embolization before the open procedure. One endograft was removed and replaced by a bifurcated Dacron graft because of distal dislocation in one patient. All patients recovered, and no deaths were recorded postoperatively. No patients had an eventful postoperative course or any subsequent graft-related complications during follow-up. CONCLUSIONS Open surgical repair involving sacotomy and suturing of the feeding vessels appeared to have good outcomes in the treatment of patients with aneurysm sac expansion caused by type II endoleaks after EVAR. Preoperative embolization of feeding vessels can thus effectively reduce intraoperative bleeding.
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Affiliation(s)
- Yepeng Zhang
- Nanjing Medical University Gulou Clinical Medical College, Nanjing, People's Republic of China
| | - Ye Ji
- Nanjing Medical University Gulou Clinical Medical College, Nanjing, People's Republic of China
| | - Guangyan Wu
- Nanjing Medical University Gulou Clinical Medical College, Nanjing, People's Republic of China
| | - Ming Zhang
- Nanjing Medical University Gulou Clinical Medical College, Nanjing, People's Republic of China
| | - Xiaoqiang Li
- Nanjing Medical University Gulou Clinical Medical College, Nanjing, People's Republic of China
| | - Min Zhou
- Nanjing Medical University Gulou Clinical Medical College, Nanjing, People's Republic of China.
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Gentsu T, Yamaguchi M, Sasaki K, Kawasaki R, Horinouchi H, Fukuda T, Miyamoto N, Mori T, Sakamoto N, Uotani K, Taniguchi T, Koda Y, Yamanaka K, Takahashi H, Okada K, Hayashi T, Watanabe T, Nomura Y, Matsushiro K, Ueshima E, Okada T, Sugimoto K, Murakami T. Side branch embolization before endovascular abdominal aortic aneurysm repair to prevent type II endoleak: A prospective multicenter study. Diagn Interv Imaging 2024; 105:326-335. [PMID: 38503637 DOI: 10.1016/j.diii.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE The purpose of the study was to evaluate the efficacy and safety of pre-emptive transcatheter arterial embolization (P-TAE) of aortic side branches to prevent type II endoleak in patients with abdominal aortic aneurysm after endovascular abdominal aneurysm repair (EVAR). MATERIALS AND METHODS This multicenter, prospective, single-arm trial enrolled 100 patients with abdominal aortic aneurysm from nine hospitals between 2018 and 2021. There were 85 men and 15 women, with a mean age of 79.6 ± 6.0 (standard deviation) years (range: 65-97 years). P-TAE was attempted for patent aortic side branches, including the inferior mesenteric artery, lumbar arteries, and other branches. The primary endpoint was late type II endoleak incidence at 6 months post-repair. Secondary endpoints included changes in aneurysmal sac diameter at 6- and 12 months, complications, re-intervention, and aneurysm-related mortality. Aneurysm sac changes at 6- and 12 months was compared between the late and no-late type II endoleak groups. RESULTS Coil embolization was successful in 80.9% (321/397) of patent aortic side branches, including 86.3% of the inferior mesenteric arteries, 80.3% of lumbar arteries, and 55.6% of other branches without severe adverse events. Late type II endoleak incidence at 6 months was 8.9% (8/90; 95% confidence interval: 3.9-16.8%). Aneurysm sac shrinkage > 5 mm was observed in 41.1% (37/90) and 55.3% (47/85) of the patients at 6- and 12-months post-EVAR, respectively. Patients with late type II endoleak had less aneurysm sac shrinkage than those without type II endoleak at 12 months (-0.2 mm vs. -6.0 mm; P = 0.040). No patients required re-intervention for type II endoleak, and no aneurysm-related mortalities occurred. CONCLUSION P-TAE is safe and effective in preventing type II endoleak, leading to early sac shrinkage at 12 months following EVAR.
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Affiliation(s)
- Tomoyuki Gentsu
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan
| | - Masato Yamaguchi
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan.
| | - Koji Sasaki
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan
| | - Ryota Kawasaki
- Department of Diagnostic and Interventional Radiology, Hyogo Prefectural Harima-Himeji General Medical Center, Himeji, Hyogo 670-8560, Japan
| | - Hiroki Horinouchi
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Osaka 565-8565, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Osaka 565-8565, Japan
| | - Naokazu Miyamoto
- Department of Radiology, Kita-harima Medical Center, Ono, Hyogo 675-1323, Japan
| | - Takeki Mori
- Department of Radiology, Japanese Red Cross Kobe Hospital, Kobe, Hyogo 651-0073, Japan
| | - Noriaki Sakamoto
- Department of Diagnostic and Interventional Radiology, Kakogawa Central City Hospital, Kakogawa, Hyogo 675-8520, Japan
| | - Kensuke Uotani
- Department of Radiology, Hyogo Prefectural Awaji Medical Center, Sumoto, Hyogo 656-0021, Japan
| | | | - Yojiro Koda
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Katsuhiro Yamanaka
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Hiroaki Takahashi
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Kenji Okada
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Taro Hayashi
- Department of Cardiovascular Surgery, Akashi Medical Center, Akashi, Hyogo 673-0896, Japan
| | - Toshitaka Watanabe
- Department of Cardiovascular Surgery, Akashi Medical Center, Akashi, Hyogo 673-0896, Japan
| | - Yoshikatsu Nomura
- Department of Cardiovascular Surgery, Hyogo Prefectural Harima-Himeji General Medical Center, Himeji, Hyogo 670-8560, Japan
| | - Keigo Matsushiro
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan
| | - Eisuke Ueshima
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan
| | - Takuya Okada
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan
| | - Koji Sugimoto
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan
| | - Takamichi Murakami
- Department of Diagnostic and Interventional Radiology, Kobe University Hospital, Kobe, 7-5-2 Kusunokicho, Chuo Ward, Kobe City, Hyogo 650-0017, Japan
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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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Rizza A, Buonpane A, Palmieri C, Berti S, Bastiani L, Prunella R, Fontana A, La Barbera G, Tusini N. Short-term outcomes of endovascular aortic aneurysm repair with the new Braile Biomédica® total custom-made abdominal endograft: Experience from three Italian centers. Curr Probl Cardiol 2024; 49:102689. [PMID: 38844267 DOI: 10.1016/j.cpcardiol.2024.102689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION Since 2019, Braile Biomédica® introduced a novel custom-made abdominal endograft tailored to the aorta's anatomy, featuring sizing every 3 mm and a diameter change from 50 mm to 8 mm. This design permits uncovered fenestrations around a single Z stent, eliminating the need for bridging stents to visceral vessels. Utilizing triple stent technology, optimal neck fixation is ensured, enabling treatment of necks shorter than 2 mm, with three 360° fenestrations optimizing graft fixation. This paper aims to analyze the initial experience with this custom-made infrarenal graft for abdominal aorta aneurysm (AAA), concerning procedural success and post-procedural short-term outcomes. RESULTS Among 12 patients treated from May 2022 to January 2024, technical success was achieved in 91.7 %, with only one intra-procedural complication. Follow-up CT scans at 1-3 months revealed resolution of an intraoperative endoleak and two late complications: a late type III endoleak and right renal artery occlusion. CONCLUSIONS The recent experience with Braile Biomédica® custom-made abdominal endograft demonstrates promising outcomes, particularly in treating AAAs with challenging anatomical features.
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Affiliation(s)
- Antonio Rizza
- Cardiology Unit, Ospedale del Cuore, Fondazione Toscana "G. Monasterio", Massa, Italy
| | - Angela Buonpane
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy.
| | - Cataldo Palmieri
- Cardiology Unit, Ospedale del Cuore, Fondazione Toscana "G. Monasterio", Massa, Italy
| | - Sergio Berti
- Cardiology Unit, Ospedale del Cuore, Fondazione Toscana "G. Monasterio", Massa, Italy
| | - Luca Bastiani
- Institute of Clinical Physiology, National Research Council, Massa, Italy
| | | | - Antonio Fontana
- Vascular Surgery Unit, SS. Annunziata Hospital, Taranto, Italy; Vascular Surgery, AO Reggio Emilia, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | | | - Nicola Tusini
- Vascular Surgery, AO Reggio Emilia, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
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Long C, Katsargyris A, Milner R, Verhoeven E. Five-Year Results for Abdominal Aortic Aneurysm Repair with the GORE® EXCLUDER® Device: Insights from the Gore Global Registry for Endovascular Aortic Treatment (GREAT). Ann Vasc Surg 2024; 106:247-254. [PMID: 38815908 DOI: 10.1016/j.avsg.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND The early postoperative benefits of endovascular aneurysm repair (EVAR) have been well established but questions remain regarding its durability at mid-term and long-term time points. Long-term results in real-world use of EVAR outside of randomized trial data are limited. This study used the Global Registry for Endovascular Aortic Treatment registry to explore the 5-year outcomes with the GORE EXCLUDER device in real-world clinical circumstances. METHODS All patients within the Global Registry for Endovascular Aortic Treatment registry who underwent an infrarenal abdominal aortic aneurysm repair with the GORE EXCLUDER device were included in this study. Baseline characteristics and demographic information of the cohort were collected. End points included mortality (all-cause and aneurysm-related), serious endoleaks, aneurysm sac diameter, endograft integrity (fracture, compression, migration), post-EVAR aortic rupture, device-related reintervention, conversion to open repair, graft explantation, and major adverse cardiovascular events. RESULTS A total of 3,216 patients were included in this analysis. The cohort reflected a significantly comorbid population with 46% of patients reaching a Charlson Comorbidity Index score of ≥5. Follow-up at 5 years was 60% of eligible participants. The freedom from aortic-related mortality was at 98.8% and overall survival was 71.2%. Postoperative major adverse cardiovascular events occurred in 49 (1.5%) patients. Device-related intervention through 5 years was 7.2% and the overall serious endoleak rate was 6.8%. Less than 1% of patients required an open conversion/revision and aortic rupture following device placement occurred in 15 (0.5%) patients. Aneurysm sac regression was achieved in 58.1% of patients at 5 years, and stability/absence of growth was observed in 83.6% at 5 years. CONCLUSIONS This study supports the durability of the GORE EXCLUDER device through 5 years with negligible incidence of graft integrity compromise and low aortic/device-related reintervention rates. Furthermore, the efficacy of the device is highlighted with low aortic-related mortality and high sac regression/stability diameter through 5 years.
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Affiliation(s)
- Chandler Long
- Division of Vascular and Endovascular Surgery, Duke University Medical Center, Durham, NC.
| | - Athanasios Katsargyris
- Division of Vascular and Endovascular Surgery, General Hospital & Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Ross Milner
- Division of Vascular Surgery, University of Chicago Medical Center, Chicago, IL
| | - Eric Verhoeven
- Division of Vascular and Endovascular Surgery, General Hospital & Paracelsus Medical University Nuremberg, Nuremberg, Germany
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Ozawa H, Ohki T, Shukuzawa K, Nakamura K, Nishide R, Kasa K, Nakagawa H, Shirouzu M, Omori M, Fukushima S. Impact of osteoporosis on overall survival following endovascular repair for abdominal aortic aneurysms. J Vasc Surg 2024:S0741-5214(24)01787-7. [PMID: 39208917 DOI: 10.1016/j.jvs.2024.08.034] [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: 07/17/2024] [Revised: 08/10/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To evaluate the impact of osteoporosis on overall survival following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs). METHODS This was a retrospective, single-center cohort study on 172 patients who had undergone primary EVAR for AAA between 2016 and 2018. Bone mineral density (BMD) was assessed by measuring the Hounsfield units (HUs) of the 11th thoracic vertebra on preoperative computed tomography; a BMD value of <110 HU was considered osteoporosis. All patients were divided into those with osteoporosis and those without osteoporosis, and long-term outcomes were compared. In addition, hazard ratios of each variable for all-cause mortality were evaluated using univariate and multivariate analysis. RESULTS All 172 patients were divided into two groups: 72 patients (41.9%) with osteoporosis and 100 patients (58.1%) without osteoporosis. The mean age was older and the mean BMD was lower in patients with osteoporosis than patients without osteoporosis (mean, 79.2 ± 7.2 years vs 75.0 ± 8.7 years, respectively; P < .05; 78.1 ± 26.7 HU vs 155.1 ± 36.3 HU, respectively; P < .05). During the median follow-up period of 68 months, overall survival was significantly lower in patients with osteoporosis than patients without osteoporosis (osteoporosis: 63.9% and 36.7% at 5 years and 7 years; nonosteoporosis: 83.8% and 74.6% at 5 years and 7 years, respectively; log-rank P < .05); freedom from aneurysm-related mortality did not differ significantly between groups (osteoporosis: 94.3% and 89.0% at 5 years and 7 years; nonosteoporosis: 100.0% and 96.7% at 5 years and 7 years, respectively; log-rank P = .078). In a multivariate analysis for overall survival after EVAR, coexistence of osteoporosis was found to be an independent risk factor for all-cause mortality (hazard ratio, 1.76; 95% confidence interval, 1.01-3.06; P < .05), as well as variables including age, statin use, sarcopenia, and aneurysm diameter. CONCLUSIONS Patients with osteoporosis showed a higher all-cause mortality after EVAR than patients without osteoporosis. We believe that comorbidity of osteoporosis may be useful in estimating the life expectancy of patients with AAA.
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Affiliation(s)
- Hirotsugu Ozawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Kota Shukuzawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Koki Nakamura
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryo Nishide
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kentaro Kasa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hikaru Nakagawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Miyo Shirouzu
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Makiko Omori
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Soichiro Fukushima
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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de Athayde Soares R, Portela MVV, Amaro K, Nasser AI, Pedrosa KDL, Sacilotto R. The Enzen Trial: Analysis of EVAR Endoprosthesis Zenith and Endurant for Infrarenal Aortoiliac Aneurysms Regarding Outcomes, Endoleaks, and Reinterventions. J Endovasc Ther 2024:15266028241270895. [PMID: 39183689 DOI: 10.1177/15266028241270895] [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: 08/27/2024]
Abstract
OBJECTIVE The main objective of this paper is to analyze the outcomes regarding endoleaks, reinterventions, and death related to aneurysm complications in patients submitted to endovascular repair (EVAR) for abdominal aortoiliac aneurysm (AAA) using Endurant II (Medtronic) and Zenith Flex (Cook) endografts. METHODS This was a prospective, consecutive cohort study of patients with AAA who underwent EVAR between January 2019 and December 2022. Two groups of patients were evaluated: Group Endurant (patients submitted to EVAR with the use of Endurant II) and Group Zenith (patients submitted to EVAR with the use of Zenith Flex). RESULTS A total of 156 patients were evaluated. Group Zenith (67 patients, 42.9%) and Group Endurant (89 patients, 57.1%). The perioperative mortality was 5.1%, eight patients (six patients Group Zenith, and two patients Group Endurant, p=0.054). There were 28 patients (17.9%) submitted to urgent repair of the aneurysm (expansion or rupture), with no differences among the groups. There were 36 cases (23.1%) of later endoleak, with a higher incidence in Zenith group (23 patients, 34.3%) than Endurant group (13 patients, 14.6%, p=0.002), most of them Type II endoleak (21 patients, 13.4%). There were 12 cases of Type I endoleak, also with a higher prevalence in Zenith group (13.4%) than Endurant group (3.4%, p=0.002). Moreover, regarding limb graft occlusion (LGO), there were nine patients (5.8%), with a higher prevalence in Zenith group (9%) than Endurant group (3.4%, p=0.045). The overall survival in a Kaplan-Meier at 720 days was 82.3% in the Zenith group and 89.1% in the Endurant group, with no statistical significance among the groups (p=0.09). The freedom from reintervention rates in a Kaplan-Meier at 720 days was 82.8% in the Zenith group and 93.2% in the Endurant group (p=0.001). CONCLUSION In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, LGO and reinterventions than patients submitted to Endurant II endografts. The linear regression analysis showed that the presence of endoleaks, type of endograft device (Zenith graft) and limb graft occlusion were related to higher reintervention rates. CLINICAL IMPACT In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, limb graft occlusions and reinterventions than patients submitted to Endurant II endografts. The main impact and the innovation that this article provides is an opportunity to evaluate and choose the best endograft suitable for the patient with AAA during EVAR.
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Affiliation(s)
- Rafael de Athayde Soares
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Matheus Veras Viana Portela
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Kaline Amaro
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Ana Izabel Nasser
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Keityane de Lima Pedrosa
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Roberto Sacilotto
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
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Sugimoto M, Horiguchi R, Ikeda S, Kawai Y, Niimi K, Hyodo R, Banno H. The immediate post-operative impact of infrarenal aortic endografts on renal arterial flow dynamics: Insights from four-dimensional flow magnetic resonance imaging analysis. Vascular 2024:17085381241277651. [PMID: 39180198 DOI: 10.1177/17085381241277651] [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: 08/26/2024]
Abstract
OBJECTIVES This study aims to quantify changes in renal blood flow before and after endovascular aneurysm repair (EVAR) using four-dimensional (4D) flow magnetic resonance imaging (MRI) and evaluate its correlation with renal impairment. METHODS In this retrospective analysis, 18 patients underwent elective EVAR for infrarenal fusiform abdominal aortic aneurysms using Excluder or Endurant endografts. 4D flow MRI scans were conducted before and 1-4 days after EVAR. Hemodynamics were quantified at the suprarenal aorta (SupAo), bilateral renal arteries (RRA and LRA), and infrarenal aorta (InfAo). Cardiac phase-resolved blood flow values (BFVs), relative flow distribution (RFD), and flow change rates (FCRs) were assessed. Estimated glomerular filtration rate (eGFR) was measured pre- and postoperatively. RESULTS A total of 16 patients were analyzed after excluding two outliers. Pre-EVAR BFVs were 23.1 ± 8.3, 3.7 ± 1.3, 3.4 ± 1.2, and 15.1 ± 5.9 mL/cycle, while post-EVAR BFVs were 20.9 ± 6.9, 3.8 ± 1.1, 3.2 ± 0.9, and 12.1 ± 4.3 mL/cycle in SupAo, RRA, LRA, and InfAo, respectively. Comparing Excluder (N = 8) and Endurant (N = 8), the total renal FCR was 121.8% [106.6-144.7] versus 101.3% [63.8-121.8] (p = 0.110), suggesting a potential improvement in renal blood flow with the Excluder, although not statistically significant. A significant correlation was found between the total renal FCR and the relative eGFR at 6 months (Spearman correlation coefficient, 0.789; p < 0.001). CONCLUSIONS The endografts, particularly the Excluder, showed potential in improving renal artery blood flow in some patients. The significant correlation between the total renal FCR and the relative eGFR at 6 months suggests that acute hemodynamic alterations induced by EVAR may impact post-operative renal function. Further research is needed to confirm these findings and assess their clinical implications.
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Affiliation(s)
- Masayuki Sugimoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryota Horiguchi
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shuta Ikeda
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yohei Kawai
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kiyoaki Niimi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryota Hyodo
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Banno
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Lengyel BC, Chinnadurai P, Corr SJ, Lumsden AB, Bavare CS. Robot-assisted vascular surgery: literature review, clinical applications, and future perspectives. J Robot Surg 2024; 18:328. [PMID: 39174843 PMCID: PMC11341614 DOI: 10.1007/s11701-024-02087-2] [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: 08/06/2024] [Accepted: 08/17/2024] [Indexed: 08/24/2024]
Abstract
Although robot-assisted surgical procedures using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) have been performed in more than 13 million procedures worldwide over the last two decades, the vascular surgical community has yet to fully embrace this approach (Intuitive Surgical Investor Presentation Q3 (2023) https://investor.intuitivesurgical.com/static-files/dd0f7e46-db67-4f10-90d9-d826df00554e . Accessed February 22, 2024). In the meantime, endovascular procedures revolutionized vascular care, serving as a minimally invasive alternative to traditional open surgery. In the pursuit of a percutaneous approach, shorter postoperative hospital stay, and fewer perioperative complications, the long-term durability of open surgical vascular reconstruction has been compromised (in Lancet 365:2179-2186, 2005; Patel in Lancet 388:2366-2374, 2016; Wanhainen in Eur J Vasc Endovasc Surg 57:8-93, 2019). The underlying question is whether the robotic-assisted laparoscopic vascular surgical approaches could deliver the robustness and longevity of open vascular surgical reconstruction, but with a minimally invasive delivery system. In the meantime, other surgical specialties have embraced robot-assisted laparoscopic technology and mastered the essential vascular skillsets along with minimally invasive robotic surgery. For example, surgical procedures such as renal transplantation, lung transplantation, and portal vein reconstruction are routinely being performed with robotic assistance that includes major vascular anastomoses (Emerson in J Heart Lung Transplant 43:158-161, 2024; Fei in J Vasc Surg Cases Innov Tech 9, 2023; Tzvetanov in Transplantation 106:479-488, 2022; Slagter in Int J Surg 99, 2022). Handling and dissection of major vascular structures come with the inherent risk of vascular injury, perhaps the most feared complication during such robotic procedures, possibly requiring emergent vascular surgical consultation. In this review article, we describe the impact of a minimally invasive, robotic approach covering the following topics: a brief history of robotic surgery, components and benefits of the robotic system as compared to laparoscopy, current literature on "vascular" applications of the robotic system, evolving training pathways and future perspectives.
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Affiliation(s)
- Balazs C Lengyel
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA.
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary.
| | - Ponraj Chinnadurai
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
| | - Stuart J Corr
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
| | - Alan B Lumsden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
| | - Charudatta S Bavare
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
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Sanders AP, Gomez-Mayorga J, Manchella MK, Swerdlow NJ, Schermerhorn ML. Ten years of physician-modified endografts. J Vasc Surg 2024:S0741-5214(24)01780-4. [PMID: 39181337 DOI: 10.1016/j.jvs.2024.07.108] [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: 05/03/2024] [Revised: 07/20/2024] [Accepted: 07/23/2024] [Indexed: 08/27/2024]
Abstract
OBJECTIVES Physician-modified endografts (PMEGs) have expanded the scope of endovascular abdominal aortic repair beyond the infrarenal aorta. Patients with prohibitively high surgical risk and visceral segment disease are often candidates for this intervention, which mitigates much of the morbidity and mortality associated with conventional open repair. Here we present the institutional PMEG experience of a high-volume aortic center. METHODS We studied all PMEGs performed at our institution from 2012 to 2023. We included cases that were submitted to the US Food sand Drug Administration in support of an investigational device exemption (IDE) trial, as well as those in the subsequently approved IDE trial. Over this 11-year period, we assessed the changes in operative characteristics and perioperative outcomes over time. Additionally, we compared the outcomes from PMEG cases to those of Zenith fenestrated (ZFEN) grafts (done by the surgeon with the PMEG IDE), an alternative device used for aneurysms involving the lower visceral segment. Here we assessed operative characteristics, perioperative outcomes, and 5-year survival and reintervention rates. RESULTS When assessing the change over time for PMEG operative characteristics, we found a trend toward decreased fluoroscopy time and decreased proportions of completion type I and type III endoleaks (all P < .05). Perioperative outcomes have remained stable over this period, with an overall perioperative mortality rate of 4.9% (noting that this registry also includes cases that were urgent and emergent). Despite the increased complexity of PMEGs relative to ZFENs, we found comparable perioperative outcomes with regard to mortality (4.9% vs 4.3%; P = .86), permanent spinal cord ischemia (1.1% vs 0%; P = .38), postoperative myocardial infarction (4.3% vs 2.9%; P = .60), postoperative respiratory failure (7.1% vs 4.3%; P = .43), and new dialysis use (2.2% vs 4.3%; P = .35). Additionally, 5-year survival (PMEG 54% vs ZFEN 65%; P = .15) and freedom from reintervention (63% vs 74%; P = .07) were similar between these cohorts. CONCLUSIONS Throughout our >10-year experience with PMEGs, we have noted improvements in operative outcomes, which can likely be attributed to technological advances and increased physician experience. Additionally, we have found that PMEGs perform well when compared with ZFENs, despite being a more complicated repair that is able to treat a larger segment of the aorta. PMEGs are crucial for the comprehensive care of vascular patients with complex aortic disease. As further operative advancements are made, we only expect the use of this intervention to increase.
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Affiliation(s)
- Andrew P Sanders
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jorge Gomez-Mayorga
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mohit K Manchella
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Nicholas J Swerdlow
- Department of Surgery, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Pastor Alconchel L, Inaraja Pérez GC, Herrando Medrano M, García Nieto B, Hidalgo Iranzo N, Marzo Álvarez AC. Influence of Proximal Fixation on Aneurysm Neck Evolution after Endovascular Treatment of Infrarenal Aneurysms. Ann Vasc Surg 2024; 109:414-423. [PMID: 39098726 DOI: 10.1016/j.avsg.2024.07.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/26/2024] [Accepted: 07/02/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND We analyzed the long-term influence of fixation systems on proximal aortic neck (PAN) evolution by comparing 2 late-generation endoprostheses, Endurant (Medtronic Vascular, Minneapolis, Minn) with suprarenal fixation (SRF) and Excluder (W.L Gore & Associates, Flagstaff, Ariz) with infrarenal fixation (IRF). METHODS Our retrospective observational study included consecutive patients undergoing endovascular aneurysm repair (EVAR) for aorto-iliac aneurysms (2011-2020). Primary end points: neck enlargement and freedom from significative PAN enlargement (5 mm). Secondary end points: neck-related reintervention, endoleaks and graft migration. Results were reported following the Society of Vascular Surgery reporting standards. RESULTS 139 patients were included (97 in SRF group and 42 in IRF group). A difference in growth at 10 mm caudal to lowest renal artery at 2 years follow-up was found (mean growth of 1.92 ± 3.38 mm in SRF and 0.16 ± 6.86 mm in IRF; P < 0.001). A tendency to a major growth in SRF at 4 years follow-up at the lowest renal artery (1.27 ± 3.36 mm vs. 0.63 ± 2.2 mm; P = 0.06), 5 mm distal to lowest renal artery (2.17 ± 3.52 mm vs. 0.94 ± 2.76 mm; P = 0.001) and 10 mm distal to lowest renal artery (2.65 ± 3.86 mm vs. 1.12 ± 1.5 mm; P < 0.001) was shown. Freedom from PAN enlargement was 96.65% and 88.20% in SRF and 100% and 94.4% in IRF at 2 and 4 years follow-up respectively (log rank 0.041). A greater incidence of type II endoleaks in IRF was observed (40.48% vs. 15.46%; P = 0.001). Oversizing >15% showed to be a risk factor of PAN enlargement (odds ratio 6.85; 95% confident interval: 1.67-28.4; P = 0.007). CONCLUSIONS A small but significative percentage of patients after EVAR show a progressive PAN enlargement, being significatively greater in SRF, without increasing neck-related complications 4 years after graft deployment.
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Affiliation(s)
| | - Gabriel Cristian Inaraja Pérez
- Angiology and Vascular Surgery Service, Lozano Blesa Clinical Hospital, Zaragoza, Spain; Grupo de Investigación en patología vascular GISSA019, Instituto de Investigación Sanitaria Aragón, Zaragoza, Aragón, Spain
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Khoury MK, Thornton MA, Eagleton MJ, Srivastava SD, Zacharias N, Dua A, Mohapatra A. Assessment of fitness for open repair in patients with infrarenal abdominal aortic aneurysms. J Vasc Surg 2024; 80:389-396.e2. [PMID: 38614140 DOI: 10.1016/j.jvs.2024.04.020] [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: 02/02/2024] [Revised: 04/04/2024] [Accepted: 04/07/2024] [Indexed: 04/15/2024]
Abstract
OBJECTIVE Endovascular aortic repair (EVAR) was originally designed as a treatment modality for patients with abdominal aortic aneurysms (AAAs) deemed unfit for open repair. However, the definition of "unfit for open repair" is largely subjective and heterogenous. The purpose of this study was to compare patients deemed unfit for open repair who underwent EVAR to a matched cohort who underwent open repair for infrarenal AAAs. METHODS The Vascular Quality Initiative of the Society for Vascular Surgery was queried for patients who underwent EVAR and open infrarenal AAA repair from 2003 to 2022. Patients that underwent EVAR were included if they were deemed unfit for open repair by the operating surgeon. EVAR patients deemed unfit because of a hostile abdomen were excluded. Patients in both the open and EVAR datasets were excluded if their repair was deemed non-elective or if they had prior aortic surgery. EVAR patients were matched to a cohort of open patients. The primary outcome for this study was 1-year mortality. Secondary outcomes included 30-day mortality, major adverse cardiac events, pulmonary complications, non-home discharge, reinterventions, and 5-year survival. RESULTS A total of 5310 EVAR patients were identified who were deemed unfit for open repair. Of those, 3028 EVAR patients (57.0%) were able to be matched 1:1 to a cohort of open patients. Open patients had higher rates of major adverse cardiac events (20.2% vs 4.4%; P < .001), pulmonary complications (12.8% vs 1.6%; P < .001), non-home discharges (28.5% vs 7.9%; P < .001), and 30-day mortality (4.5% vs 1.4%; P < .001). There were no differences in early survival, but open repair had better middle and late survival compared with EVAR over the course of 5 years. A total of 74 EVAR patients (2.4%) had reinterventions during the study period. EVAR patients that required interventions had higher 1-year (40.5% vs 7.3%; P < .001) and 5-year mortality (43.2% vs 14.1%; P < .001) compared with those that did not require reinterventions. EVAR patients who had reinterventions had higher 1-year (40.5% vs 6.3%; P < .001) and 5-year (43.2% vs 20.3%; P = .006) mortality compared with their matched open cohort. CONCLUSIONS Patients undergoing EVAR for AAAs who are deemed unfit for open repair have better perioperative morbidity and mortality compared with open repair. However, patients who had an open repair had better middle and late survival over the course of 5 years. The categorization of unfitness for open surgery may be inaccurate and re-evaluation of this terminology/concept should be undertaken.
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Affiliation(s)
- Mitri K Khoury
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA.
| | - Micah A Thornton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Sunita D Srivastava
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Abhisekh Mohapatra
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
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Ozawa H, Ohki T, Shukuzawa K, Kasa K, Yamada Y, Nakagawa H, Shirouzu M, Omori M, Fukushima S, Tachihara H. Midterm outcomes of endovascular repair for abdominal aortic aneurysm using the cuff-first technique to prevent type II endoleaks. J Vasc Surg 2024; 80:397-404. [PMID: 38631517 DOI: 10.1016/j.jvs.2024.04.034] [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: 02/03/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE The aim of this study was to evaluate the initial and midterm outcomes of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) using the cuff-first technique (CFT) to prevent type II endoleak (T2EL). METHODS CFT involves deploying an aortic cuff inside the AAA to cover the ostium of the aortic side branch vessels before deploying the main body. We performed a retrospective review of all patients undergoing EVAR with CFT or side branch embolization (SBE) for AAAs at The Jikei University Hospital between 2016 and 2022. Primary endpoint was the rate of aneurysm sac shrinkage. Secondary endpoints were procedure time, radiation exposure, technical and clinical success rates, occurrence of T2EL, and freedom from reintervention or aneurysm-related death. RESULTS Of 406 patients who underwent EVAR for AAAs, CFT was utilized in 56 (CFT group) and SBE in 35 (SBE group); all 91 patients were included in this study. There were no differences in patient demographics between groups, but there were differences in patency rate of the inferior mesenteric artery and absent intraluminal thrombus. The technical success rate per target vessel in the CFT and SBE group was 97.8% and 91.8%, and the clinical success rate was 91.0% and 100%, respectively. The median procedure time was shorter for CFT than for SBE: CFT, 10 (interquartile range [IQR], 6-14) minutes vs SBE, 25 (IQR, 18.5-45) minutes; P < .05), and median radiation exposure was lower for CFT than for SBE (CFT, 1455 (IQR, 840-2634) mGy vs SBE, 2353 (IQR, 1552-3586) mGy; P < .05). During the median follow-up of 25 months (IQR, 12.5-47 months), sac shrinkage occurred at similar rates in both groups (CFT, 37.5% vs SBE, 40.0%; P = .812), and there were no differences in freedom from reintervention (CFT, 96.2% and 91.4% at 12 and 36 months vs SBE, 100% and 89.5% at 12 and 36 months; log-rank P = .761) and freedom from aneurysm-related death (100% at 36 months in both groups; log-rank P = .440). The odds ratio of CFT vs SBE for sac regression was calculated by adjusting for inferior mesenteric artery patency and absent intraluminal thrombus, resulting in no statistical significance (odds ratio, 1.231; 95% confidence interval, 0.486-3.122). CONCLUSIONS CFT is feasible with a shorter procedure time and lower radiation exposure than SBE and comparable mid-term outcomes, including sac shrinkage rate, compared with SBE. We believe that CFT, if anatomically suitable, is an alternative to SBE for the prevention of T2EL during EVAR.
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Affiliation(s)
- Hirotsugu Ozawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Kota Shukuzawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kentaro Kasa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuta Yamada
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hikaru Nakagawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Miyo Shirouzu
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Makiko Omori
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Soichiro Fukushima
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiromasa Tachihara
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Ozawa H, Ohki T, Shukuzawa K, Kasa K, Yamada Y, Nakagawa H, Shirouzu M, Omori M, Fukushima S, Tachihara H. Ten-year single-center outcomes following endovascular repair for abdominal aortic aneurysm using the INCRAFT device. J Vasc Surg 2024; 80:405-412. [PMID: 38485069 DOI: 10.1016/j.jvs.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE This study aimed to report the long-term outcomes beyond 10 years of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms using the low-profile INCRAFT device. METHODS This was a single-center, retrospective cohort study of all patients undergoing EVAR using the INCRAFT device as part of the regulatory trial between 2012 and 2013. Primary endpoint was aneurysm-related death. Secondary endpoints were all-cause death, reintervention, late open conversion, and aneurysm status (shrinkage, stable, and growth). RESULTS Thirty patients with a mean age of 71.8 ± 7.7 years were included in this study. The median aneurysm diameter at EVAR was 54.5 mm (interquartile range, 53-56.8 mm). All abdominal aortic aneurysms in this study were treated following the device's instructions for use. At index EVAR, the INCRAFT device was successfully implanted in all patients using a percutaneous approach under local anesthesia. No patients experienced major adverse events or procedure-related complications 30 days after EVAR. During the median follow-up of 125 months (interquartile range, 98-131 months) with follow-up rates of 100% at 5 years and 96.7% at 10 years, aneurysm-related mortality was 0%, and freedom from all-cause mortality was 82.9% at 5 years and 75.3% at 10 years. Reintervention was required in 10 patients with 15 procedures. Sac growth was observed in 11 patients (36.7%), six of whom eventually required late open conversion; five of these patients underwent open aneurysmorrhaphy with stent graft preservation, and one underwent open surgical repair with endograft explantation. Late rupture was identified in one case, where type Ia endoleak led to rupture at 69 months, and open repair was successfully performed. Freedom from reintervention was 89.0% at 5 years but declined to 60.9% at 10 years; freedom from late open conversion was 100% at 5 years but declined to 70.8% at 10 years. CONCLUSIONS Long-term outcomes of the INCRAFT stent graft showed no aneurysm-related deaths. However, sac growth occurred persistently throughout the follow-up period, resulting in a relatively high rate of reinterventions in the later periods, which highlights the importance of lifelong postoperative surveillance and appropriate reinterventions when indicated.
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Affiliation(s)
- Hirotsugu Ozawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Kota Shukuzawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kentaro Kasa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuta Yamada
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hikaru Nakagawa
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Miyo Shirouzu
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Makiko Omori
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Soichiro Fukushima
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiromasa Tachihara
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Yu J, Khamzina Y, Kennedy J, Liang NL, Hall DE, Arya S, Tzeng E, Reitz KM. The association between frailty and outcomes following ruptured abdominal aortic aneurysm repair. J Vasc Surg 2024; 80:379-388.e3. [PMID: 38614142 DOI: 10.1016/j.jvs.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/28/2024] [Accepted: 04/07/2024] [Indexed: 04/15/2024]
Abstract
OBJECTIVE Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysms (AAAs). Early postoperative outcomes are associated with both patients; physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAAs (rAAAs). METHODS Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI) (robust, ≤20; normal, 21-29; frail, 30-39; very frail, ≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Interaction terms evaluated the association's moderation. RESULTS We identified 5806 patients (age, 72 ± 9 years; 77% male; EVAR, 65%; robust, 6%; normal, 48%; frail, 36%; very, frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR (aHR, 1.43; 95% CI, 1.19-1.73) was associated with increased 1-year mortality when compared with EVAR. Increasing frailty status (frail aHR, 1.26; 95% CI, 1.00-1.59; very frail aHR, 1.64; 95% CI, 1.26-2.13) was associated with increased 1-year mortality, which was moderated by repair type (P-interaction < .05). OSR was associated with increased 1-year mortality in normal (aHR, 1.49; 95% CI, 1.20-1.87) and frail (aHR, 1.51; 95% CI, 1.20-1.89), but not among robust (aHR, 0.88; 95% CI, 0.59-1.32) and very frail (aHR, 1.29; 95% CI, 0.97-1.72) patients. CONCLUSIONS Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared with EVAR. However, there was no difference between OSR and EVAR among robust patients who can well tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.
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Affiliation(s)
- Jia Yu
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Jason Kennedy
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Surgery Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, PA
| | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA.
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Donik Ž, Li W, Nnate B, Pugar JA, Nguyen N, Milner R, Cerda E, Pocivavsek L, Kramberger J. A computational study of artery curvature and endograft oversize influence on seal zone behavior in endovascular aortic repair. Comput Biol Med 2024; 178:108745. [PMID: 38901185 PMCID: PMC11317088 DOI: 10.1016/j.compbiomed.2024.108745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/18/2024] [Accepted: 06/08/2024] [Indexed: 06/22/2024]
Abstract
Thoracic endovascular aortic repair (TEVAR) is a minimally invasive procedure involving the placement of an endograft inside the dissection or an aneurysm to direct blood flow and prevent rupture. A significant challenge in endovascular surgery is the geometrical mismatch between the endograft and the artery, which can lead to endoleak formation, a condition where blood leaks between the endograft and the vessel wall. This study uses computational modeling to investigate the effects of artery curvature and endograft oversizing, the selection of an endograft with a larger diameter than the artery, on endoleak creation. Finite element analysis is employed to simulate the deployment of endografts in arteries with varying curvature and diameter. Numerical simulations are conducted to assess the seal zone and to quantify the potential endoleak volume as a function of curvature and oversizing. A theoretical framework is developed to explain the mechanisms of endoleak formation along with proof-of-concept experiments. Two main mechanisms of endoleak creation are identified: local buckling due to diameter mismatch and global buckling due to centerline curvature mismatch. Local buckling, characterized by excess graft material buckling and wrinkle formation, increases with higher levels of oversizing, leading to a larger potential endoleak volume. Global buckling, where the endograft bends or deforms to conform to the centerline curvature of the artery, is observed to require a certain degree of oversizing to bridge the curvature mismatch. This study highlights the importance of considering both curvature and diameter mismatch in the design and clinical use of endografts. Understanding the mechanisms of endoleak formation can provide valuable insights for optimizing endograft design and surgical planning, leading to improved clinical outcomes in endovascular aortic procedures.
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Affiliation(s)
- Žiga Donik
- Faculty of Mechanical Engineering, University of Maribor, Smetanova ulica 17, 2000 Maribor, Slovenia.
| | - Willa Li
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, The University of Chicago, 5841 S Maryland Ave, MC 5028, Chicago, IL 60637, USA
| | - Blessing Nnate
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, The University of Chicago, 5841 S Maryland Ave, MC 5028, Chicago, IL 60637, USA
| | - Joseph A Pugar
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, The University of Chicago, 5841 S Maryland Ave, MC 5028, Chicago, IL 60637, USA
| | - Nhung Nguyen
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, The University of Chicago, 5841 S Maryland Ave, MC 5028, Chicago, IL 60637, USA
| | - Ross Milner
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, The University of Chicago, 5841 S Maryland Ave, MC 5028, Chicago, IL 60637, USA
| | - Enrique Cerda
- Departamento de Física, Facultad de Ciencia, Universidad de Santiago de Chile (USACH), Santiago Chile
| | - Luka Pocivavsek
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, The University of Chicago, 5841 S Maryland Ave, MC 5028, Chicago, IL 60637, USA.
| | - Janez Kramberger
- Faculty of Mechanical Engineering, University of Maribor, Smetanova ulica 17, 2000 Maribor, Slovenia
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Nielsen AC, Nicolajsen CW, Eldrup N. Abdominal Aortic Aneurysm Repair in Patients with Concomitant Cancer: A Literature Review. Vascular 2024; 32:717-727. [PMID: 36812403 DOI: 10.1177/17085381231159151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVES Abdominal aortic aneurysmal (AAA) repair in patients with concomitant cancer is controversial due to increased comorbidity and reduced life expectancy in this specific patient group. This literature review aims to investigate the evidence supporting one treatment modality over another (endovascular aortic repair (EVAR) or open repair (OR)), as well as treatment strategy (staged AAA-, cancer first or simultaneous procedures) in patients with AAA and concomitant cancer. METHODS Literature review, including studies published from 2000 to 2021 on surgical treatment in patients with AAA and concomitant cancer and related outcomes (30-day morbidity/complications as well as 30-day and 3-year mortality). RESULTS 24 studies comprising 560 patients undergoing surgical treatment of AAA and concomitant cancer were included. Of these, 220 cases were treated with EVAR and 340 with OR. Simultaneous procedures were performed in 190 cases, 370 received staged procedures. The 30-day mortality for EVAR versus OR was 1% and 8%, corresponding to a relative risk (RR) of 0.11 (95% CI: 0.03-0.46, p = 0.002). No difference in mortality was observed between staged versus simultaneous procedure nor between AAA-first versus cancer-first strategy, RR 0.59 (95% CI: 0.29-1.1, p = 0.13) and 0.88 (95% CI 0.34-2.31, p = 0.80), respectively. Overall, 3-year mortality was 21% for EVAR and 39% for OR from 2000-2021, while the mortality up to 3 years after EVAR within recent years (2015-2021) was 16%. CONCLUSION This review supports EVAR treatment as first choice if suitable. No consensus was established on treating either the aneurysm or the cancer first or simultaneously. Long-term mortality after EVAR was comparable to non-cancer patients within recent years.
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Affiliation(s)
- Anne C Nielsen
- Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Chalotte W Nicolajsen
- Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark
- Department of Cardiology, Thrombosis Research Unit, Aalborg University Hospital, Aalborg, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
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Gutierrez RD, Pepic L, Lancaster EM, Gasper WJ, Hiramoto JS, Conte MS, Bongiovanni T, Iannuzzi JC. Early Opioid Use and Postoperative Delirium Following Open Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2024; 109:338-349. [PMID: 39069121 DOI: 10.1016/j.avsg.2024.07.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 06/06/2024] [Accepted: 07/01/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Postoperative delirium is a common complication following open abdominal aortic aneurysm repair (OAR). Opioids have been found to contribute to delirium, especially at higher doses. This study assessed the impact of early postoperative opioid analgesia on postoperative delirium incidence and time to onset. We hypothesized that higher early postoperative opioid utilization would be associated with increased postoperative delirium incidence. METHODS This was a retrospective analysis of OAR cases at a single quaternary care center from years 2012-2020. The primary exposure was oral morphine equivalents use (OME), calculated for postoperative days 1-7. A cut point analysis using a receiver operator curve for postoperative delirium determined the threshold for high OME (OME>37 mg). The primary outcome was postoperative delirium incidence identified via chart review. Multivariable logistic regression was performed for postoperative delirium and adjusted for covariates meeting P < 0.1 on bivariate analysis. RESULTS Among 194 OAR cases, 67 (35%) developed postoperative delirium with median time to onset of 3 days (IQR = 2-6). Patients with postoperative delirium were older (74 years vs. 69 years), more frequently presented with symptomatic AAA (47% vs. 27%) and had a higher proportion of comorbidities (all P < 0.05). Cases with high OME utilization on postoperative day 1 (55%) were younger (69 vs. 73 years), less frequently had an epidural (46% vs. 77%), and more frequently developed delirium (42% vs. 25%, all P < 0.05). Epidural use was associated with a significant decrease in OME utilization on postoperative day 1 (33 vs. 83, P < 0.01). Postoperative delirium onset was later in those with high OME use (4 vs. 2 days, P = 0.04). On multivariable analysis, high OME remained associated with postoperative delirium (Table II). CONCLUSIONS High opioid utilization on postoperative day 1 is associated with increased postoperative delirium and epidural along with acetaminophen use reduced opioid utilization. Future study should examine the impact of opioid reduction strategies on outcomes after major vascular surgery.
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Affiliation(s)
- Richard D Gutierrez
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Lejla Pepic
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | | | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade S Hiramoto
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Tasce Bongiovanni
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
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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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Soares RDA, Amaro K, Nasser AI, Cury MVM, Nakamura ET, Pedrosa KDL, Sacilotto R. Endovascular repair for infra-renal aortic aneurysms with supra-renal fixation endoprosthesis: Results and outcomes. Vascular 2024:17085381241264381. [PMID: 39030072 DOI: 10.1177/17085381241264381] [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: 07/21/2024]
Abstract
OBJECTIVE The main objective of this paper is to evaluate the outcomes regarding endoleaks, reinterventions, and death related to aneurysm complications in patients submitted to endovascular repair (EVAR) for abdominal aortoiliac aneurysm (AAA) using Endurant II (Medtronic) and Zenith Flex (Cook) endografts. METHODS This was a prospective, consecutive cohort study of patients with AAA who underwent EVAR with the use of Endurant II stent graft and Zenith Flex endograft. RESULTS A total of 156 patients submitted to EVAR were evaluated. The perioperative mortality was 5.1%, 8 patients. The median clinical follow-up period was 760 ± 80 days. There were 28 patients (17.9%) submitted to urgent repair of the aneurysm (symptomatic expansion or rupture) and 128 patients (82.1%) submitted to elective repair. There were 36 cases (23.1%) of later endoleak and most of them are Type II endoleaks (21 patients, 13.4%). There were 12 cases of Type I endoleak. Moreover, regarding limb graft occlusion (LGO), there were 9 patients (5.8%). The overall survival rate in Kaplan-Meier analysis at 720 days was 84.8% in the total cohort. The freedom from reintervention rate in Kaplan-Meier analysis at 720 days was 92.7% in the total cohort. The linear regression analysis for survival rates showed that chronic kidney disease (p = .03; hazard ratio (HR) = 2.82, CI = 1.07-4.44) was the only factor related to poorer survival rates in both univariate and multivariate analyses. The linear regression analysis showed that the presence of endoleaks (p < .001, HR = 6.69, CI = 2.26-8.48) and limb graft occlusion (p < .001, HR = 8.02, CI = 1.60-9.99) were related to reintervention in both univariate and multivariate analyses. CONCLUSION In this present study, supra-renal fixation endograft devices were safe and efficient in treating AAA, with satisfactory results and no renal compromise. The linear regression analysis showed that the presence of endoleaks and limb graft occlusion were related to higher reintervention rates in both univariate and multivariate analyses.
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Affiliation(s)
- Rafael de Athayde Soares
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Kaline Amaro
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Ana Isabel Nasser
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Marcus Vinícius Martins Cury
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Edson Takamitsu Nakamura
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Keityane de Lima Pedrosa
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Roberto Sacilotto
- Division of Vascular and Endovascular Surgery, Hospital Do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
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Suzuki T, Mitsuoka H, Terai Y, Miyano Y. Remodeling of the Proximal Sealing Zone and Sac Shrinkage after Endovascular Aortic Repair or Fenestrated Endovascular Aortic Repair. Ann Vasc Surg 2024; 109:47-54. [PMID: 39029892 DOI: 10.1016/j.avsg.2024.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/07/2024] [Accepted: 06/16/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND Variations in sac shrinkage (SS) are noted between endovascular aneurysm repair for abdominal aortic aneurysm (AAA) and fenestrated endovascular aneurysm repair for short neck AAA. These variations may originate from difference in the geometry and length of proximal sealing, which influences the quality and durability of the seal. This study aimed to explore the disparities in aneurysm exclusion and sac remodeling across these 2 scenarios. METHODS This study involved a retrospective analysis of prospectively collected data from 2014 to 2021. Of 486 endovascular abdominal aortic repair cases, 33 that exclusively used a low permeability expanded polytetrafluoroethylene infrarenal device, strictly adhering to the instructions for use (IFUs), were selected. Concurrently, 30 cases of fenestrated repair that utilized modified polyester woven fabric devices proximally with consistent use of the aforementioned low-permeability devices infrarenally were examined. The quality of both proximal and distal sealing zones in fenestrated repairs was maintained within the range specified in the expanded polytetrafluoroethylene infrarenal device's IFUs, ensuring consistent sealing integrity for reliable group comparisons. Key metrics used for analysis were the detection of endoleaks and measurements of sac dimensions. Additional analyses included comparisons of demographic data and postoperative diameter changes in the proximal sealing zone (PZ) (encompassing 0, 5, 10, 15, and 20 mm below the most proximal sealing stent). RESULTS The demographic data and preoperative maximum-minimum diameter of the aneurysms did not differ between the groups. Proximal neck dilatation was similarly observed after both procedures. Immediately after the procedure, the incidence of lumbar arterial type II endoleaks was significantly lower after fenestrated repair than that after endovascular aortic repair (EVAR, 10% vs. 39.4%, P = 0.0094). At the final observation, EVAR substantially reduced the PZ length (-4.73 ± 15.30%), while fenestrated repair maintained the length (21.98 ± 24.34%; P < 0.0001). The preservation of the sealing length in fenestrated repairs was attributable to dilation occurring within the sealing range of the proximal device, oversized to accommodate the larger diameters in the more proximal sections of the aorta. The cumulative occurrence of SS (>5 mm) following fenestrated repair increased faster than that after endovascular repair (P = 0.002). CONCLUSIONS Although aortic neck dilatation progressed similarly in both groups, fenestrated repair maintained the sealing length and demonstrated a greater extent of SS, even under the challenging circumstances in PZ. The superior postoperative results were linked to both the durability of proximal sealing and a lower occurrence of lumbar arterial type II endoleaks, stemming from the effective shuttering of the collateral sources in the proximal lumbar or intercostal arteries.
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Affiliation(s)
- Takahiro Suzuki
- Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan.
| | - Hiroshi Mitsuoka
- Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yasuhiko Terai
- Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yuta Miyano
- Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
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Ricci G, Gibelli F, Sirignano A, Taurino M, Sirignano P. Physician-Modified Endografts for Repair of Complex Abdominal Aortic Aneurysms: Clinical Perspectives and Medico-Legal Profiles. J Pers Med 2024; 14:759. [PMID: 39064014 PMCID: PMC11278265 DOI: 10.3390/jpm14070759] [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: 06/07/2024] [Revised: 07/08/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
Standard endovascular aortic repair (EVAR) has become the standard of care for treating infrarenal abdominal aortic aneurysms (AAAs) in patients with favorable anatomies, while patients with challenging AAA anatomies, and those with suprarenal or thoraco-abdominal aneurysms, still need alternative, more complex, solutions, including custom-made branched or fenestrated grafts, which are constrained by production delay and costs. To address urgent needs and complex cases, physicians have proposed modifying standard endografts by manually creating graft fenestrations. This allows for effective aneurysm exclusion and satisfactory patency of visceral vessels. Although physician-modified grafts (PMEGs) have demonstrated high technical success, standardized creation processes and long-term safety data are still lacking, necessitating further study to validate their clinical and legal standing. The aim of this article is to illustrate the state of the art with regard to this surgical technique, summarizing its origin, evolution, and the main clinical evidence supporting its effectiveness. The paper also aims to discuss the main medico-legal issues related to the use of PMEGs, with particular reference to the issue of safety related to the standardization of the surgical technique, medical liability profiles, and informed consent.
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Affiliation(s)
- Giovanna Ricci
- Section of Legal Medicine, School of Law, University of Camerino, 62032 Camerino, Italy; (G.R.); (A.S.)
| | - Filippo Gibelli
- Section of Legal Medicine, School of Law, University of Camerino, 62032 Camerino, Italy; (G.R.); (A.S.)
| | - Ascanio Sirignano
- Section of Legal Medicine, School of Law, University of Camerino, 62032 Camerino, Italy; (G.R.); (A.S.)
| | - Maurizio Taurino
- Vascular and Endovascular Surgery Unit, Sant’Andrea Hospital of Rome, Department of Molecular and Clinical Medicine, “Sapienza” University of Rome, 00185 Rome, Italy;
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Sant’Andrea Hospital of Rome, Department of General and Specialistic Surgery, “Sapienza” University of Rome, 00185 Rome, Italy;
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Ueda T, Fujitsuna R, Saito H, Yasui D, Sugihara F, Mine T, Shirai S, Matsumoto T, Kurita J, Ishii Y, Hayashi H, Kumita SI. Preemptive Embolization of Abdominal Aortic Aneurysm Sac Side Branch Arteries Promotes Early Sac Shrinkage after Endovascular Aneurysm Repair 1. Ann Vasc Surg 2024; 109:9-19. [PMID: 39025215 DOI: 10.1016/j.avsg.2024.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 06/02/2024] [Accepted: 06/06/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND The association between the occlusion rate of the side branch arteries branching from the abdominal aortic aneurysm sac and aneurysm sac shrinkage is unclear. We aimed to evaluate the efficacy of preemptive embolization of multiple side branch arteries branching from the abdominal aortic aneurysm sac in early aneurysm sac shrinkage after endovascular aneurysm repair. METHODS Patients undergoing endovascular aneurysm repair of abdominal aortic aneurysms, with or without preemptive embolization of multiple side branch arteries, including the inferior mesenteric artery and lumbar arteries, between January 2016 and August 2021, were retrospectively evaluated. Preemptive embolization was introduced at our institution in January 2018 and has been performed in all patients who undergo endovascular aneurysm repair since then. We compared occlusion rates of the side branch arteries, frequency of type 2 endoleaks, changes in aneurysm sac size, percentage of aneurysm sac size decrease, and frequency of reduction in the aneurysm sac diameter by > 5 mm. RESULTS The study included 43 patients in the embolization group and 20 in the nonembolization group. Preemptive embolization was successfully performed without any ischemic complications. The total occlusion rate of side branch arteries was significantly higher in the embolization group than in the nonembolization group (70.2% vs. 29.3%, P < 0.05). At 24 months of follow-up, the type 2 endoleak frequency was significantly lower in the embolization group than in the nonembolization group (6.9% vs. 31.6%, P < 0.05). The frequency of reduction in the aneurysm sac diameter by > 5 mm was significantly higher in the embolization group than in the nonembolization group at 24 months (62.1% vs. 31.6% P < 0.05). The optimal cutoff value for the total occlusion rate of the side branch arteries to achieve reduction in the aneurysm sac diameter by > 5 mm at 24 months, after endovascular aneurysm repair, was 66.7% in all patients (area under the curve = 0.634; sensitivity = 62.5%; specificity = 70.8%). These findings suggest that occluding 66.7% or more of the side branch arteries may result in early aneurysmal shrinkage. CONCLUSIONS Preemptive embolization of multiple side branch arteries, branching from the abdominal aortic aneurysm sac, may contribute to early aneurysm sac shrinkage; this may serve as a marker for fewer late complications after endovascular aneurysm repair.
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Affiliation(s)
- Tatsuo Ueda
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan.
| | - Ryutaro Fujitsuna
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Hidemasa Saito
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Daisuke Yasui
- Department of Radiology, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Fumie Sugihara
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Takahiko Mine
- Department of Radiology, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Chiba, Japan
| | - Sayaka Shirai
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Taiga Matsumoto
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Jiro Kurita
- Department of Cardiovascular Surgery, Hanyu General Hospital, Hanyu, Saitama, Japan
| | - Yosuke Ishii
- Department of Cardiovascular Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Hiromitsu Hayashi
- Department of Radiology, Nippon Medical School Hospital, Tokyo, Japan
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Azhar B, Holt P. No-Cross: Bridging the Innovation Gap. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00572-0. [PMID: 38977058 DOI: 10.1016/j.ejvs.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 06/17/2024] [Accepted: 07/02/2024] [Indexed: 07/10/2024]
Affiliation(s)
- Bilal Azhar
- St Georges Vascular Institute, St Georges University London, St Georges Hospital NHS Trust, London, UK.
| | - Peter Holt
- St Georges Vascular Institute, St Georges University London, St Georges Hospital NHS Trust, London, UK
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Kang J. Does "no pain, no gain" hold true for patients with aortic aneurysms? J Vasc Surg 2024; 80:96-97. [PMID: 38906669 DOI: 10.1016/j.jvs.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 03/01/2024] [Indexed: 06/23/2024]
Affiliation(s)
- Jeanwan Kang
- University of Maryland School of Medicine, Division of Vascular Surgery, Baltimore, MD
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Smorenburg SPM, de Bruin JL, Zeebregts CJ, Reijnen MMPJ, Verhagen HJM, Heyligers JMM. Long Term Outcomes of the Gore Excluder Low Permeability Endoprosthesis for the Treatment of Infrarenal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2024; 68:18-27. [PMID: 38527519 DOI: 10.1016/j.ejvs.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 02/23/2024] [Accepted: 03/21/2024] [Indexed: 03/27/2024]
Abstract
OBJECTIVE This study evaluated the long term outcomes of endovascular aneurysm repair using the Gore Excluder Low Permeability (LP) endoprosthesis across high volume Dutch hospitals. METHODS A retrospective analysis was conducted of patients treated with the Excluder LP for infrarenal abdominal aortic aneurysm (AAA) in four hospitals between 2004 and 2017. Primary outcomes were overall survival, freedom from re-interventions (overall, inside and outside instructions for use, IFU), and AAA sac dynamics: growth (> 5 mm), stabilisation, and regression (< 5 mm). Secondary outcomes were technical success (device deployment), procedural parameters, and re-interventions. Follow up visits were extracted from patient files, with imaging assessed for complications and AAA diameter. RESULTS Five hundred and fourteen patients were enrolled, with a median (IQR) follow up of 5.0 (2.9, 6.9) years. Survival rates were 94.0% at one year, 73.0% at five years, and 37.0% at 10 years, with freedom from re-interventions of 89.0%, 79.0%, and 71.0%, respectively. 37.9% were treated outside IFU, leading to significantly more re-interventions over 10 years compared with those treated inside IFU (36.0% vs. 25.0%, respectively; p = .044). The aneurysm sac regressed by 53.5% at one year, 65.8% at five years, and 77.8% at 10 years, and grew by 9.8%, 14.3%, and 22.2%, respectively. Patients with one year sac growth had significantly worse survival (p = .047). Seven patients (1.4%) had a ruptured aneurysm during follow up. Over 15 years, type 1a endoleak occurred in 5.3%, type 1b in 3.1%, type 3 in 1.9%, type 4 in 0.2%, and type 2 in 35.6% of patients. CONCLUSION This multicentre study of real world endovascular aneurysm repair data using the Gore Excluder LP endoprosthesis demonstrated robust long term survival and re-intervention rates, despite 37.9% of patients being treated outside IFU, with type 4 endoleak being rare. Treatment outside IFU significantly increased re-intervention rates and one year sac growth was associated with statistically significantly worse survival.
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Affiliation(s)
- Stefan P M Smorenburg
- Department of Surgery, Amsterdam University Medical Centres location Vrije Universiteit, Amsterdam, the Netherlands
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Michel M P J Reijnen
- Department of Surgery, Rijnstate, Arnhem, the Netherlands; Multi-Modality Medical Imaging Group, University of Twente, Enschede, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Jan M M Heyligers
- Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands.
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Ji J, Bi J, Chen Y, Zhang X, Zhao B, Liang H, Fan J, Dai X. Mid-term outcomes of different treatments of internal iliac artery in endovascular aneurysm repair. Sci Prog 2024; 107:368504241274998. [PMID: 39252493 PMCID: PMC11388315 DOI: 10.1177/00368504241274998] [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: 09/11/2024]
Abstract
OBJECTIVE To evaluate the mid-term outcomes of different treatment strategies for the internal iliac artery (IIA) during EVAR. METHODS This was a retrospective study. All patients undergoing EVAR, who required treatment of at least one side of IIA from January 2013 to July 2022 in a single center, were included. According to the different treatment strategies for IIA, the patients were divided into UP (unilateral preservation), BP (bilateral preservation) and BE (bilateral embolization) groups. The primary outcomes included buttock claudication, bowel ischemia and iliac-related reintervention. Then patients who underwent IIA reconstruction were divided into IPG (iliac parallel stent graft) and IBG (iliac branch stent graft) groups according to the reconstruction technique. The primary outcomes included endoleak, iliac branch occlusion and iliac-related reintervention. RESULTS A total of 237 patients were included, including 167 in the UP group, 9 in the BP group and 61 in the BE group. The mean follow-up time was 39.0 ± 27.7, 50.0 ± 22.1 and 25.8 ± 18.9 months in UP, BP and BE groups, respectively. Thirty cases (12.7%) of buttock claudication occurred, and it was significantly higher in the BE group than the UP group (26.2% vs. 7.8%, p < 0.001). There were no significant differences in the other follow-up outcomes among three groups. The K-M analysis indicated that the patients in the BE group had a lower survival rate than those in the other two groups (p = 0.024). 24 patients underwent IIA reconstruction, including 8 in the IPG group and 16 in the IBG group. The endoleak in the IBG group was significantly lower than that in the IPG group (0% vs. 25.0%, p = 0.041). The iliac-related reintervention, iliac occlusion and mortality were similar between the two groups. CONCLUSION Overall it is beneficial for patients to preserve at least one side of IIA during EVAR as much as possible. Compared with IPG, IBG might be more applicable for IIA reconstruction.
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Affiliation(s)
- Jie Ji
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jiaxue Bi
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yonghui Chen
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaoxing Zhang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Bin Zhao
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Hao Liang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jibo Fan
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiangchen Dai
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
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