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Vakhitov D, Grandhomme J, Kuntz S, Christ L, Neumann N, Heim F, Chakfé N, Lejay A. Editor's Choice -- Type IIIb Endoleaks: Fabric Perforations of Explanted New Generation Endoprostheses. Eur J Vasc Endovasc Surg 2024; 67:446-453. [PMID: 37717814 DOI: 10.1016/j.ejvs.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/20/2023] [Accepted: 09/11/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVE To analyse explanted endografts (EGs) and describe fabric degradation responsible for type IIIb endoleaks. METHODS As part of the European collaborative retrieval programme, 32 EGs with fabric defects on macroscopic evaluation were selected. The explanted EGs were processed and studied based on the ISO 9001 certified standard protocol. It includes instructions on the collection, transportation, cleaning, and examination of explanted material. The precise analysis was performed with a digital microscope of 20 - 200 times magnification. Possible perforation mechanisms were assessed in stress tests. RESULTS The median time to explantation of the 32 EGs was 54 months. The explants included 65 separate EG modules, with 46 (70.8%) having a combined 388 fabric perforations. Each EG had a median of 4.79 mm2 (interquartile range [IQR] 9.86 mm2) of cumulated hole area (an average of 0.13% of an EG's area). There were 239 (61.6%) expanded polytetrafluoroethylene (ePTFE; 11 EGs) and 149 (38.4%) polyethylene terephthalate (PET; 21 EGs) fabric ruptures, with no difference in hole distribution between these types of material. Overall, 126 (32.5%) stent related and 262 (67.5%) non-stent related fabric perforations were identified. Perforations caused by fabric fatigue in ePTFE (151, 63.2%) and material kinking in PET (41, 27.5%) were the most common. The stent related perforations were larger in size (0.80 mm2) than non-stent related perforations (0.19 mm2); p < .001. Wider interstent spaces and prolonged implantation duration were associated with an increased risk of stent related perforation development; p < .001 and p = .004, respectively. Large stent related perforations were also detected in the short term, suggesting mechanical issues as underlying causes. CONCLUSION The fabric of EGs may degrade and lead to the development of perforations. The largest perforations are stent related. Their occurrence and size depend on the implantation time and the EG shape affected by arterial tortuosity. The conclusions are limited to the samples from a select explant group.
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Affiliation(s)
| | - Jonathan Grandhomme
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Salomé Kuntz
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | | | | | - Frédéric Heim
- GEPROMED, Strasbourg, France; Laboratoire de Physique et Mécanique Textile, Université de Haute-Alsace, Mulhouse, France
| | - Nabil Chakfé
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Anne Lejay
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
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DeMartino RR, Breite MD, Neal D, Mendes BC, Colglazier JJ, Stone DH, Scali ST. Incidence, reintervention, and survival associated with type II endoleak at hospital discharge after elective endovascular aneurysm repair in the Vascular Quality Initiative. J Vasc Surg 2023; 78:679-686.e1. [PMID: 37257671 DOI: 10.1016/j.jvs.2023.05.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/01/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND The longitudinal clinical significance of type II endoleaks (T2ELs) remains controversial. Specifically, the real-world incidence, need for reintervention, and associated mortality referable to T2ELs remain unknown. Moreover, current professional society clinical practice guidelines recommend differing aneurysm sac growth thresholds to prompt intervention. Therefore, the purpose of this analysis was to better quantify the prevalence of early T2ELs after infrarenal endovascular aortic aneurysm repair (EVAR) and determine its association with reintervention and survival. METHODS All elective EVARs from the Vascular Quality Initiative (2010-2020) were examined to identify patients with isolated T2ELs vs no endoleak (NONE) at discharge. Procedures with a type I or III endoleak were excluded. A subgroup analysis was performed on patients surviving beyond the first postoperative year with follow-up data available on endoleaks. The primary outcome was overall survival. Secondary outcomes included perioperative mortality and reinterventions. Outcomes were assessed by multivariable logistic and Cox proportional hazards regression to adjust for covariates. RESULTS We identified 53,697 patients who underwent EVAR. The overall incidence of isolated T2ELs at discharge was 16%. In-hospital mortality was lower for those with isolated T2ELs vs NONE (0.8% vs 1.9%, odds ratio: 0.6, 95% confidence interval: 0.5-0.8, P < .0001). Unadjusted overall survival was marginally higher at 5 years for patients with T2ELs vs NONE (84% vs 82%); however, after risk adjustment, survival was similar (hazard ratio: 0.95, 95% confidence interval: 0.9-1.0). Among 44,345 patients with 1-year follow-up, 66% had data on endoleak status for assessment. Survival was similar regardless of endoleak status (NONE, at discharge only, at follow-up only, or at both time points). Among patients with documented T2ELs during follow-up, 6.1% and 2.5% had abdominal aortic aneurysm sac diameter growth ≥5 mm and ≥10 mm, respectively. Reinterventions occurred in 12%. Rupture (1%) and any open reintervention (4%) were rare among patients with 1-year follow-up. For patients with T2ELs, 5-year survival was similar between those with and without reintervention by 1 year (89% vs 91%, log-rank P = .06). CONCLUSIONS T2ELs remain common after EVAR within the Vascular Quality Initiative and are not associated with long-term mortality. Reinterventions for T2ELs were not associated with improved overall survival among patients with T2ELs. Although additional data surrounding the appropriate role of reintervention for T2ELs remain necessary, it appears that the natural history of T2ELs is benign.
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Affiliation(s)
| | - Matthew D Breite
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Dan Neal
- Division of Vascular and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Salvatore T Scali
- Division of Vascular and Endovascular Therapy, University of Florida, Gainesville, FL
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Yanamaladoddi VR, Sarvepalli SS, Vemula SL, Aramadaka S, Mannam R, Sankara Narayanan R, Bansal A. The Challenge of Endoleaks in Endovascular Aneurysm Repair (EVAR): A Review of Their Types and Management. Cureus 2023; 15:e39775. [PMID: 37398777 PMCID: PMC10312356 DOI: 10.7759/cureus.39775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
An abdominal aortic aneurysm (AAA) is a dilatation of the abdominal aorta above 3 cm or 50% greater than the segment above. It is a dangerous condition accounting for a substantial number of deaths per year and increasing at an alarming rate. Various factors come into play in the development of AAAs, which this study has elaborated on, including smoking and old age, demographics, and comorbid conditions. Endovascular aneurysm repair (EVAR) is a newer treatment modality used for AAAs in which an endograft device is placed into the aorta, thereby creating a bypass tract from the aneurysm and generating flow mimicking that of the natural aorta. It is minimally invasive and associated with less postoperative mortality and reduced hospital stay. However, EVAR is also associated with significant postoperative complications, including endoleaks, which were reviewed in depth. Endoleaks are postprocedural leaks into the aneurysm sac that are usually identified immediately after graft placement and indicate treatment failure. They are of five subtypes, categorized according to their mechanism of development. The most common type is type II endoleaks, and the most dangerous is type I endoleaks. Each subtype has multiple management options with varying rates of success. Prompt identification along with appropriate treatment of endoleaks can lead to better postoperative outcomes and improved quality of life for patients.
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Affiliation(s)
| | | | | | | | - Raam Mannam
- Research, Narayana Medical College, Nellore, IND
| | | | - Arpit Bansal
- Research, Narayana Medical College, Nellore, IND
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Suliemeh Y, Bouabane M, Deershamarkha M, Benzirar A, El Mahi O. Type III Endoleak Leading to Aortic Rupture After Endovascular Repair. Cureus 2022; 14:e26895. [PMID: 35978736 PMCID: PMC9375828 DOI: 10.7759/cureus.26895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2022] [Indexed: 12/04/2022] Open
Abstract
Endovascular treatment of abdominal aortic aneurysm concerns the introduction of aortic endoprosthesis which aims to isolate aneurysm from the circulation. The leading complication of this technique is the endoleak which is defined by the persistence of blood flow within the aneurysm sac. The main risk is the rupture of the aorta which can jeopardize the vital prognosis of patient. White classification defines five types of endoleaks. Type III is secondary either to a disconnection between the components of the endoprosthesis (type IIIA) or to material damage (type IIIB). This type presents a particularly high risk of aortic rupture. Endovascular approach is the treatment of choice for this type of endoleaks through stent-grafts implantation. Type III endoleak may appear at any time after endovascular aortic aneurysm repair (EVAR). Although the frequency of endoleak after EVAR has been reduced after improvement and development of stent-graft systems, there are still many improvements and additions expected to improve the prognoses for patients after EVAR. Our case is an 80-year-old patient, who received an EVAR in 2012 for his abdominal aortic aneurysm, admitted to our vascular surgery department for a type III endoleak, for which he benefited from an endovascular treatment by placement of stent-grafts.
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Flohr TR, Snow R, Aziz F. The fate of endoleaks after endovascular aneurysm repair and the impact of oral anticoagulation on their persistence. J Vasc Surg 2021; 74:1183-1192.e5. [PMID: 33940069 DOI: 10.1016/j.jvs.2021.04.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 04/13/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The impact of anticoagulation on late endoleaks after endovascular aneurysm repair (EVAR) is unclear despite multiple investigators studying the relationship. The purpose of this study was to determine if long-term anticoagulation impacted the development of late endoleaks and if specific anticoagulants were more likely to exacerbate the development of endoleaks. METHODS Using the Society for Vascular Surgery Vascular Quality Initiative database, patients undergoing EVAR between 2003 and 2019 for abdominal aortic aneurysms were evaluated. Patients were divided into two groups: those without a late endoleak and those with a late endoleak. Bivariate analysis was performed to assess preoperative, intraoperative, postoperative, and long-term follow-up variables. A multivariable analysis was done to determine associations of independent variables with late endoleaks. Patients were further subcategorized based on anticoagulation status before and after EVAR, specific type of anticoagulation, and the presence of an index endoleaks (diagnosed at the time of EVAR) to determine the subsequent frequency of late endoleaks. RESULTS A total of 29,783 patients were analyzed with 2169 (7.3%) having a late endoleak identified. Several risk factors were related to late endoleaks, including anticoagulation before and after EVAR (odds ratio [OR], 4.23; 95% confidence interval [CI], 2.57-6.96; P < .001), anticoagulation after EVAR (OR, 1.88; 95% CI, 1.43-2.49; P < .001), and index endoleak (OR, 1.45; 95% CI, 1.26-1.66; P < .001). The frequency of late endoleaks in patients anticoagulated before and after EVAR and after EVAR as compared with those never anticoagulated was 16.89% and 14.40% vs 6.95%, respectively (both P > .001). No difference in late endoleaks were noted for patients treated with warfarin and novel oral anticoagulants. The most common type of index and late endoleak identified was type II, but patients with type I, type II, and type IV index endoleaks were more commonly found to have type I, type II, and type IV late endoleaks, respectively. The frequency of late endoleaks in patients with both an index endoleak and anticoagulation after EVAR was 20.42% as compared with patients with only anticoagulation after EVAR (14.63%; P = .0015) and with patients with index endoleaks not anticoagulated (10.06%; P < .00001). CONCLUSIONS Late endoleaks were more common in patients treated with anticoagulation after EVAR. No difference in late endoleak frequency was detected between anticoagulation with warfarin and novel oral anticoagulants. Patients on anticoagulation and those with an index endoleak were at a higher risk of having a late endoleak.
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Affiliation(s)
- Tanya R Flohr
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Penn State College of Medicine, Hershey, Pa.
| | - Rachael Snow
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Penn State College of Medicine, Hershey, Pa
| | - Faisal Aziz
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Penn State College of Medicine, Hershey, Pa
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Charisis N, Bouris V, Conway AM, Labropoulos N. A Systematic Review and Pooled Meta-Analysis on the Incidence and Temporal Occurrence of Type II Endoleak Following an Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2021; 75:406-419. [PMID: 33549794 DOI: 10.1016/j.avsg.2021.01.083] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/02/2021] [Accepted: 01/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim in this study was to systematically review the literature to identify the time of occurrence of a newly diagnosed Type II endoleak (T2E) following an endovascular aneurysm repair (EVAR) for an infrarenal abdominal aortic aneurysm (AAA) and its potential impact on aneurysmal sac diameter changes. METHODS A comprehensive systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane until January 2020. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess for heterogeneity. RESULTS Thirty-three observational studies were deemed eligible and provided data for 2643 T2E detected following EVAR. A total of 1432 (54.2%) T2E were diagnosed before 30 days follow-up, while 1035 (39.1%) T2E were diagnosed beyond 30 days following EVAR. A total of 222 (8.4%) T2E were diagnosed after 12 months of follow-up. A pooled meta-analysis of 6 studies, showed that early diagnosed T2E had a statistically significant higher odds of resolving as compared to those detected late (OR: 2.41; 95% CI: 1.14-5.09; P = 0.021; I2 = 68.9%). Sac expansion was documented in 313 (29%) T2E. The ruptured endoleaks were 14 (1.1%). CONCLUSIONS The occurrence of a T2E is a dynamic process detected throughout the lifetime of a patient with 8% detected beyond 12 months following EVAR. Long-term follow up is required with future prospective studies with consist reporting on changes in sac diameter, the thrombus characteristics. Long-term outcomes are needed to optimize management of patients with a newly diagnosed T2E.
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Affiliation(s)
- Nektarios Charisis
- Department of Vascular Surgery, Stony Brook University, Stony Brook, New York, USA
| | - Vasileios Bouris
- Department of Surgery, Lenox Hill Hospital, New York City, New York, USA
| | - Allan M Conway
- Department of Surgery, Lenox Hill Hospital, New York City, New York, USA
| | - Nicos Labropoulos
- Department of Vascular Surgery, Stony Brook University, Stony Brook, New York, USA.
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Abstract
Most abdominal aortic aneurysms are treated with endovascular repair (EVAR) in current practice. EVAR has lower periprocedural mortality and morbidity than open surgical repair. Aneurysm neck morphology, iliac anatomy, and access vessel anatomy need careful assessment for the successful performance of EVAR. Regular and long-term follow-up with imaging is mandatory after EVAR, and patients who are less likely to comply are less favorable EVAR candidates. Endoleaks are the most frequent complication of EVAR. Most can be managed with transcatheter or endovascular means. Evolving technology and techniques are allowing more patients to be treated with EVAR with better long-term outcomes.
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Affiliation(s)
- Akshit Sharma
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, 3901 Rainbow Boulevard, Delp 1001, Kansas City, KS 66160, USA
| | - Prince Sethi
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, 3901 Rainbow Boulevard, Delp 1001, Kansas City, KS 66160, USA
| | - Kamal Gupta
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, 3901 Rainbow Boulevard, Delp 1001, Kansas City, KS 66160, USA.
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Madigan MC, Singh MJ, Chaer RA, Al-Khoury GE, Makaroun MS. Occult type I or III endoleaks are a common cause of failure of type II endoleak treatment after endovascular aortic repair. J Vasc Surg 2019; 69:432-439. [DOI: 10.1016/j.jvs.2018.04.054] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/20/2018] [Indexed: 10/28/2022]
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Nakai M, Ikoma A, Loffroy R, Kamisako A, Higashino N, Sonomura T. Endovascular management of endotension by graft reinforcement followed by direct sac embolization. MINIM INVASIV THER 2018; 28:234-240. [DOI: 10.1080/13645706.2018.1518918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Motoki Nakai
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama, Japan
| | - Akira Ikoma
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama, Japan
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, François-Mitterrand Teaching Hospital, University of Bourgogne, Dijon, France
| | - Atsufumi Kamisako
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama, Japan
| | - Nobuyuki Higashino
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama, Japan
| | - Tetsuo Sonomura
- Department of Radiology, Wakayama Medical University, Wakayamashi, Wakayama, Japan
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Nakai M, Ikoma A, Loffroy R, Midulla M, Kamisako A, Higashino N, Fukuda K, Sonomura T. Type II endoleak model creation and intraoperative aneurysmal sac embolization with n-butyl cyanoacrylate-lipiodol-ethanol mixture (NLE) in swine. Quant Imaging Med Surg 2018; 8:894-901. [PMID: 30505718 DOI: 10.21037/qims.2018.10.01] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The purpose of this study was to evaluate the feasibility of type II endoleak model creation and efficacy of intraoperative aneurysmal sac embolization using n-butyl-2-cyanoacrylate-lipiodol-ethanol mixture (NLE) for type II endoleak in swine. Methods In six swine (mean body weight 53.5 kg), abdominal aortic aneurysm (AAA) was created and then end-to-side anastomosis between the left renal artery and AAA sac was performed. And then, endovascular abdominal aortic aneurysm repair (EVAR) was performed, leading to creation of a type II endoleak model. As control group, EVAR without sac embolization was performed in two swine. In four swine, AAA sac was embolized using NLE immediately after EVAR via the microcatheter placed in AAA sac (NLE embolization group). Follow-up aortography was performed immediately and three days after the procedure, and then the aneurysms were extracted. Results The AAA sac and type II endoleak model were successfully created in all cases. In control group, type II endoleak persisted three days after the procedure. In NLE embolization group, endoleak disappeared immediately and three days after the procedure. In NLE embolization group, AAA sac was occupied with thrombus and embolic material. Inflammatory changes were recognized in aneurysmal sac wall in NLE embolization group. Conclusions This experimental study suggests that creation of a type II endoleak model in swine is feasible and that intraoperative AAA sac embolization with NLE during EVAR might reduce the occurrence of type II endoleak.
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Affiliation(s)
- Motoki Nakai
- Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Akira Ikoma
- Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
| | - Atsufumi Kamisako
- Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | | | - Kodai Fukuda
- Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Tetsuo Sonomura
- Department of Radiology, Wakayama Medical University, Wakayama, Japan
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Identification of Anatomical Risk Factors for Type II Endoleak to Guide Selective Inferior Mesenteric Artery Embolization. Ann Vasc Surg 2018; 48:166-173. [DOI: 10.1016/j.avsg.2017.10.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 09/06/2017] [Accepted: 10/09/2017] [Indexed: 11/17/2022]
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The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018; 67:2-77.e2. [DOI: 10.1016/j.jvs.2017.10.044] [Citation(s) in RCA: 1150] [Impact Index Per Article: 191.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abraha I, Luchetta ML, De Florio R, Cozzolino F, Casazza G, Duca P, Parente B, Orso M, Germani A, Eusebi P, Montedori A. Ultrasonography for endoleak detection after endoluminal abdominal aortic aneurysm repair. Cochrane Database Syst Rev 2017; 6:CD010296. [PMID: 28598495 PMCID: PMC6481872 DOI: 10.1002/14651858.cd010296.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND People with abdominal aortic aneurysm who receive endovascular aneurysm repair (EVAR) need lifetime surveillance to detect potential endoleaks. Endoleak is defined as persistent blood flow within the aneurysm sac following EVAR. Computed tomography (CT) angiography is considered the reference standard for endoleak surveillance. Colour duplex ultrasound (CDUS) and contrast-enhanced CDUS (CE-CDUS) are less invasive but considered less accurate than CT. OBJECTIVES To determine the diagnostic accuracy of colour duplex ultrasound (CDUS) and contrast-enhanced-colour duplex ultrasound (CE-CDUS) in terms of sensitivity and specificity for endoleak detection after endoluminal abdominal aortic aneurysm repair (EVAR). SEARCH METHODS We searched MEDLINE, Embase, LILACS, ISI Conference Proceedings, Zetoc, and trial registries in June 2016 without language restrictions and without use of filters to maximize sensitivity. SELECTION CRITERIA Any cross-sectional diagnostic study evaluating participants who received EVAR by both ultrasound (with or without contrast) and CT scan assessed at regular intervals. DATA COLLECTION AND ANALYSIS Two pairs of review authors independently extracted data and assessed quality of included studies using the QUADAS 1 tool. A third review author resolved discrepancies. The unit of analysis was number of participants for the primary analysis and number of scans performed for the secondary analysis. We carried out a meta-analysis to estimate sensitivity and specificity of CDUS or CE-CDUS using a bivariate model. We analysed each index test separately. As potential sources of heterogeneity, we explored year of publication, characteristics of included participants (age and gender), direction of the study (retrospective, prospective), country of origin, number of CDUS operators, and ultrasound manufacturer. MAIN RESULTS We identified 42 primary studies with 4220 participants. Twenty studies provided accuracy data based on the number of individual participants (seven of which provided data with and without the use of contrast). Sixteen of these studies evaluated the accuracy of CDUS. These studies were generally of moderate to low quality: only three studies fulfilled all the QUADAS items; in six (40%) of the studies, the delay between the tests was unclear or longer than four weeks; in eight (50%), the blinding of either the index test or the reference standard was not clearly reported or was not performed; and in two studies (12%), the interpretation of the reference standard was not clearly reported. Eleven studies evaluated the accuracy of CE-CDUS. These studies were of better quality than the CDUS studies: five (45%) studies fulfilled all the QUADAS items; four (36%) did not report clearly the blinding interpretation of the reference standard; and two (18%) did not clearly report the delay between the two tests.Based on the bivariate model, the summary estimates for CDUS were 0.82 (95% confidence interval (CI) 0.66 to 0.91) for sensitivity and 0.93 (95% CI 0.87 to 0.96) for specificity whereas for CE-CDUS the estimates were 0.94 (95% CI 0.85 to 0.98) for sensitivity and 0.95 (95% CI 0.90 to 0.98) for specificity. Regression analysis showed that CE-CDUS was superior to CDUS in terms of sensitivity (LR Chi2 = 5.08, 1 degree of freedom (df); P = 0.0242 for model improvement).Seven studies provided estimates before and after administration of contrast. Sensitivity before contrast was 0.67 (95% CI 0.47 to 0.83) and after contrast was 0.97 (95% CI 0.92 to 0.99). The improvement in sensitivity with of contrast use was statistically significant (LR Chi2 = 13.47, 1 df; P = 0.0002 for model improvement).Regression testing showed evidence of statistically significant effect bias related to year of publication and study quality within individual participants based CDUS studies. Sensitivity estimates were higher in the studies published before 2006 than the estimates obtained from studies published in 2006 or later (P < 0.001); and studies judged as low/unclear quality provided higher estimates in sensitivity. When regression testing was applied to the individual based CE-CDUS studies, none of the items, namely direction of the study design, quality, and age, were identified as a source of heterogeneity.Twenty-two studies provided accuracy data based on number of scans performed (of which four provided data with and without the use of contrast). Analysis of the studies that provided scan based data showed similar results. Summary estimates for CDUS (18 studies) showed 0.72 (95% CI 0.55 to 0.85) for sensitivity and 0.95 (95% CI 0.90 to 0.96) for specificity whereas summary estimates for CE-CDUS (eight studies) were 0.91 (95% CI 0.68 to 0.98) for sensitivity and 0.89 (95% CI 0.71 to 0.96) for specificity. AUTHORS' CONCLUSIONS This review demonstrates that both ultrasound modalities (with or without contrast) showed high specificity. For ruling in endoleaks, CE-CDUS appears superior to CDUS. In an endoleak surveillance programme CE-CDUS can be introduced as a routine diagnostic modality followed by CT scan only when the ultrasound is positive to establish the type of endoleak and the subsequent therapeutic management.
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Affiliation(s)
- Iosief Abraha
- Regional Health Authority of UmbriaHealth Planning ServicePerugiaItaly06124
| | | | - Rita De Florio
- Local Health UnitAzienda SanitariaLocale USL 1, Medicina GeneralePerugiaItaly
| | - Francesco Cozzolino
- Regional Health Authority of UmbriaVia Mario Angeloni 61PerugiaUnbriaItaly06124
| | - Giovanni Casazza
- Università degli Studi di MilanoDipartimento di Scienze Biomediche e Cliniche "L. Sacco"via GB Grassi 74MilanItaly20157
| | - Piergiorgio Duca
- Ospedale Luigi SaccoL.I.T.A. Polo UniversitarioVia G.B. Grassi, 74MilanoItaly20157
| | - Basso Parente
- Azienda Ospedaliera di PerugiaChirurgia VascolareSant' Andrea delle FrattePerugiaItaly06156
| | - Massimiliano Orso
- Regional Health Authority of UmbriaHealth Planning ServicePerugiaItaly06124
| | - Antonella Germani
- Azienda Unita' Sanitaria Locale Umbria N. 2Servizio Immunotrasfusionalevia ArcamoneFolignoItaly06034
| | - Paolo Eusebi
- Regional Health Authority of UmbriaEpidemiology DepartmentVia Mario Angeloni 61PerugiaUmbriaItaly06124
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Prophylactic Intraoperative Embolization of Abdominal Aortic Aneurysm Sacs Using N -Butyl Cyanoacrylate/Lipiodol/Ethanol Mixture with Proximal Neck Aortic Balloon Occlusion during Endovascular Abdominal Aortic Repair. J Vasc Interv Radiol 2016; 27:954-60. [DOI: 10.1016/j.jvir.2016.03.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 03/19/2016] [Accepted: 03/19/2016] [Indexed: 11/18/2022] Open
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15
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Lahoz C, Gracia CE, García LR, Montoya SB, Hernando ÁB, Heredero ÁF, Tembra MS, Velasco MB, Guijarro C, Ruiz EB, Pintó X, de Ceniga MV, Moñux Ducajú G. [Not Available]. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2016; 28 Suppl 1:1-49. [PMID: 27107212 DOI: 10.1016/s0214-9168(16)30026-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Carlos Lahoz
- Unidad de Lípidos y Riesgo Vascular, Servicio de Medicina Interna, Hospital Carlos III, Madrid, España.
| | - Carlos Esteban Gracia
- Servicio de Angiología y Cirugía Vascular, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | | | - Sergi Bellmunt Montoya
- Servicio de Angiología y Cirugía Vascular, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Ángel Brea Hernando
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital San Pedro, Logroño, España
| | | | - Manuel Suárez Tembra
- Unidad de Lípidos y Riesgo Cardiovascular, Servicio de Medicina Interna, Hospital San Rafael, A Coruña, España
| | - Marta Botas Velasco
- Servicio de Angiología y Cirugía Vascular, Hospital de Cabueñes, Gijón, España
| | - Carlos Guijarro
- Consulta de Riesgo Vascular, Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - Esther Bravo Ruiz
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario de Basurto, Bilbao, España
| | - Xavier Pintó
- Unidad de Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario de Bellvitge, L' Hospitalet de Llobregat, Barcelona, España
| | - Melina Vega de Ceniga
- Servicio de Angiología y Cirugía Vascular, Hospital de Galdakao-Usansolo, Vizcaya, España
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Nakai M, Ikoma A, Sato H, Sato M, Nishimura Y, Okamura Y. Risk factors associated with late aneurysmal sac expansion after endovascular abdominal aortic aneurysm repair. Diagn Interv Radiol 2016; 21:195-201. [PMID: 25858524 DOI: 10.5152/dir.2014.14308] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to identify the risk factors associated with late aneurysmal sac expansion after endovascular abdominal aortic aneurysm repair (EVAR). METHODS We retrospectively reviewed contrast-enhanced computed tomography (CT) images of 143 patients who were followed for ≥6 months after EVAR. Sac expansion was defined as an increase in sac diameter of 5 mm relative to the preoperative diameter. Univariate and multivariate analyses were performed to identify associated risk factors for late sac expansion after EVAR from the following variables: age, gender, device, endoleak, antiplatelet therapy, internal iliac artery embolization, and preprocedural variables (aneurysm diameter, proximal neck diameter, proximal neck length, suprarenal neck angulation, and infrarenal neck angulation). RESULTS Univariate analysis revealed female gender, endoleak, aneurysm diameter ≥60 mm, suprarenal neck angulation >45°, and infrarenal neck angulation >60° as factors associated with sac expansion. Multivariate analysis revealed endoleak, aneurysm diameter ≥60 mm, and infrarenal neck angulation >60° as independent predictors of sac expansion (P < 0.05, for all). CONCLUSION Our results suggest that patients with small abdominal aortic aneurysms (<60 mm) and infrarenal neck angulation ≤60° are more favorable candidates for EVAR. Intraprocedural treatments, such as prophylactic embolization of aortic branches or intrasac embolization, may reduce the risk of sac expansion in patients with larger abdominal aortic aneurysms or greater infrarenal neck angulation.
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Affiliation(s)
- Motoki Nakai
- Department of Radiology, Wakayama Medical University, Wakayama, Japan.
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17
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Endofugas tipo 2 en una población tratada con endoprótesis Gore® Excluder: incidencia, persistencia y crecimiento del saco aneurismático. ANGIOLOGIA 2015. [DOI: 10.1016/j.angio.2015.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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18
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Ioannou CV, Kontopodis N, Georgakarakos E, Dalainas I. Commentary: transcaval approach in the management of a type I endoleak associated with the ovation stent-graft system. J Endovasc Ther 2015; 22:431-5. [PMID: 25900724 DOI: 10.1177/1526602815583821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Efstratios Georgakarakos
- Vascular Surgery Unit, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Ilias Dalainas
- Vascular Surgery Department, University of Athens, Athens, Greece
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Torres-Blanco Á, Schmidt A, Gómez-Palonés F, Ortiz-Monzón E. The Roadside Technique for Type II Endoleak Embolization 4 Years after Endovascular Aortic Aneurysm Repair. Ann Vasc Surg 2015; 29:837.e13-6. [PMID: 25681172 DOI: 10.1016/j.avsg.2014.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 10/26/2014] [Accepted: 11/04/2014] [Indexed: 10/24/2022]
Abstract
Endoleaks are the most common cause of reintervention after endovascular aortic aneurysm repair (EVAR). Type II endoleaks have been implicated as a risk factor for expansion and rupture. Several techniques have been described to manage type II endoleaks, being transarterial catheterization the most commonly used. In some cases this technique can be difficult or impossible to achieve. We report the use of a technique that offers a direct access to the aneurysm sac and the possibility of catheterization of the involved vessels or the embolization of the communication between them, even 4 years after EVAR.
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Affiliation(s)
- Álvaro Torres-Blanco
- Department of Angiology, Endovascular and Vascular Surgery, Hospital Universitario Dr. Peset, Valencia, Spain.
| | - Andrej Schmidt
- Center for Vascular Medicine, Angiology and Vascular Surgery, Park Hospital, Leipzig, Germany
| | - Francisco Gómez-Palonés
- Department of Angiology, Endovascular and Vascular Surgery, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Eduardo Ortiz-Monzón
- Department of Angiology, Endovascular and Vascular Surgery, Hospital Universitario Dr. Peset, Valencia, Spain
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20
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Utility of 99mTc–Human Serum Albumin Diethylenetriamine Pentaacetic Acid SPECT for Evaluating Endoleak After Endovascular Abdominal Aortic Aneurysm Repair. AJR Am J Roentgenol 2015; 204:189-96. [DOI: 10.2214/ajr.13.12383] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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21
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Avgerinos ED, Chaer RA, Makaroun MS. Type II endoleaks. J Vasc Surg 2014; 60:1386-1391. [DOI: 10.1016/j.jvs.2014.07.100] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 07/28/2014] [Indexed: 10/24/2022]
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22
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23
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Nakai M, Sato H, Ikoma A, Sonomura T, Sato M. The use of technetium-99m-labeled human serum albumin diethylenetriamine pentaacetic acid single-photon emission CT scan in the follow-up of type II endoleak treatment. J Vasc Interv Radiol 2014; 25:405-9. [PMID: 24581463 DOI: 10.1016/j.jvir.2013.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 12/08/2013] [Accepted: 12/08/2013] [Indexed: 11/28/2022] Open
Abstract
An 84-year-old woman presented with persistent type II endoleak with sac expansion from 57 mm to 75 mm during 4-year follow-up after endovascular abdominal aortic aneurysm repair. The patient underwent transabdominal embolization with coils and N-butyl cyanoacrylate/ethiodized oil (Lipiodol; Guerbet, Villepinte, France) mixture (2.5 mL). Because of the anticipated embolization artifacts on follow-up computed tomography (CT), technetium-99m-labeled human serum albumin diethylenetriamine pentaacetic acid single-photon emission computed tomography ((99m)Tc-HSAD SPECT) was performed before and after the intervention. Perigraft accumulation on (99m)Tc-HSAD SPECT corresponding to the endoleak disappeared after embolization. CT scan performed 12 months after embolization showed no signs of sac expansion. (99m)Tc-HSAD SPECT may be useful for evaluating therapeutic effect after embolization for endoleak.
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Affiliation(s)
- Motoki Nakai
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama 641-8510, Japan.
| | - Hirotatsu Sato
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama 641-8510, Japan
| | - Akira Ikoma
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama 641-8510, Japan
| | - Tetsuo Sonomura
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama 641-8510, Japan
| | - Morio Sato
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama 641-8510, Japan
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Abstract
PURPOSE OF REVIEW To review the current state of diagnosis, treatment, and outcomes of the different types of endoleaks after endovascular abdominal aortic aneurysm repair (endovascular aneurysm repair, EVAR). RECENT FINDINGS Endoleaks are the most frequent complication after EVAR, the most common indication for secondary interventions, and the most common cause of rupture after EVAR. Imaging is critical for detecting endoleaks. Type I and III endoleaks require urgent intervention to prevent aneurysm rupture. Intervention for other endoleaks or endotension is indicated if the aneurysm sac continues to grow during follow-up. The majority of endoleaks can be treated with endovascular techniques. Open surgical conversion may be considered if the risk of aneurysm rupture is high and if no endovascular options are available or if they have failed. SUMMARY Endoleaks continue to be a challenge and this article discusses the different treatment options for endoleaks after EVAR. Long-term follow-up after EVAR is required to diagnose and treat endoleaks before they result in aneurysm rupture. The majority of endoleaks can be treated with endovascular techniques, although open surgical interventions may be required in selected patients.
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25
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Clinical significance of endoleaks characterized by computed tomography during aortography performed immediately after endovascular abdominal aortic aneurysm repair: prediction of persistent endoleak. Jpn J Radiol 2012; 31:16-23. [DOI: 10.1007/s11604-012-0137-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 09/17/2012] [Indexed: 10/27/2022]
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Marchiori A, von Ristow A, Guimaraes M, Schönholz C, Uflacker R. Predictive Factors for the Development of Type II Endoleaks. J Endovasc Ther 2011; 18:299-305. [DOI: 10.1583/10-3116.1] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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27
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Moll FL, Powell JT, Fraedrich G, Verzini F, Haulon S, Waltham M, van Herwaarden JA, Holt PJE, van Keulen JW, Rantner B, Schlösser FJV, Setacci F, Ricco JB. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg 2011; 41 Suppl 1:S1-S58. [PMID: 21215940 DOI: 10.1016/j.ejvs.2010.09.011] [Citation(s) in RCA: 996] [Impact Index Per Article: 76.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Accepted: 09/12/2010] [Indexed: 12/11/2022]
Affiliation(s)
- F L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, The Netherlands.
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28
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Arthurs ZM, Lyden SP, Rajani RR, Eagleton MJ, Clair DG. Long-Term Outcomes of Palmaz Stent Placement for Intraoperative Type Ia Endoleak During Endovascular Aneurysm Repair. Ann Vasc Surg 2011; 25:120-6. [DOI: 10.1016/j.avsg.2010.08.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2010] [Revised: 08/16/2010] [Accepted: 08/18/2010] [Indexed: 11/29/2022]
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Walker TG, Kalva SP, Yeddula K, Wicky S, Kundu S, Drescher P, d'Othee BJ, Rose SC, Cardella JF. Clinical Practice Guidelines for Endovascular Abdominal Aortic Aneurysm Repair: Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association. J Vasc Interv Radiol 2010; 21:1632-55. [DOI: 10.1016/j.jvir.2010.07.008] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 05/24/2010] [Accepted: 07/11/2010] [Indexed: 12/17/2022] Open
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Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, Timaran CH, Upchurch GR, Veith FJ. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg 2009; 50:S2-49. [PMID: 19786250 DOI: 10.1016/j.jvs.2009.07.002] [Citation(s) in RCA: 453] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 07/06/2009] [Accepted: 07/06/2009] [Indexed: 02/08/2023]
Affiliation(s)
- Elliot L Chaikof
- Department of Surgery, Emory University, Atlanta, Ga 30322, USA.
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31
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Kranokpiraksa P, Kaufman JA. Follow-up of Endovascular Aneurysm Repair: Plain Radiography, Ultrasound, CT/CT Angiography, MR Imaging/MR Angiography, or What? J Vasc Interv Radiol 2008; 19:S27-36. [DOI: 10.1016/j.jvir.2008.03.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2008] [Revised: 03/07/2008] [Accepted: 03/07/2008] [Indexed: 11/25/2022] Open
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32
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Katzen BT, MacLean AA. Complications of Endovascular Repair of Abdominal Aortic Aneurysms: A Review. Cardiovasc Intervent Radiol 2006; 29:935-46. [PMID: 16967225 DOI: 10.1007/s00270-005-0191-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The endovascular procedure for repair of abdominal aortic aneurysms has had an enormous impact on the treatment of this challenging disease. Complications, however, do occur and it is important to have a thorough understanding of the array of complications and appropriate management strategies. In this review of endovascular complications, we describe early and late complications paying particular attention to preventive, treatment and surveillance strategies.
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Affiliation(s)
- Barry T Katzen
- Department of Interventional Radiology, Baptist Cardiac and Vascular Institute, Baptist Health Systems, Miami, Florida, USA.
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33
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AbuRahma AF. Fate of Endoleaks Detected by CT Angiography and Missed by Color Duplex Ultrasound in Endovascular Grafts for Abdominal Aortic Aneurysms. J Endovasc Ther 2006; 13:490-5. [PMID: 16928163 DOI: 10.1583/06-1874r.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To analyze the clinical implications of endoleaks documented by computed tomographic angiography (CTA) and missed by color duplex ultrasound (CDU). METHODS During a recent 5-year period, 232 patients underwent endovascular aortic reconstruction (EVAR) and were followed according to a protocol that included CTA and CDU at 1 month and every 6 months thereafter. CTA was the gold standard for determining the presence of endoleaks. The size of the AAA sac at the latest postoperative follow-up was compared to the preoperative size and correlated to the type of endoleak and clinical outcome. This study analyzed only patients with endoleak documented by CTA and CDU and specifically analyzed the outcome of patients with false negative CDU studies for endoleaks. RESULTS Thirty-nine endoleaks were documented in 35 (15%) of 232 patients using CTA. Four patients had both early and late endoleaks. The mean follow-up was 25 months (range 1-64). CDU was more helpful in detecting type I endoleaks than type II endoleaks (89% versus 58%, p<0.05). There were 18 (46%) type I endoleaks (12 early, 6 late) detected by CTA; 16 (89%) of these were detected by CDU (2 late endoleaks missed). Nineteen (49%) type II endoleaks (16 early, 3 late) were diagnosed using CTA, 11 (58%) of which were detected by CDU (6 early and 2 late missed). Of the 2 (5%) early type IV endoleaks found on CTA, 1 (50%) was missed by CDU. Overall, CDU failed to identify endoleak in 11 (28%) of 39 endoleaks [2 late type I, 8 type II (6 early, 2 late), and 1 early type IV]. Consequences to treatment occurred in 2 (20%): 1 type I endoleak required treatment and 1 type II endoleak would have missed treatment. CONCLUSION CDU has a lower sensitivity in detecting endoleak, particularly type II; therefore, EVAR surveillance should not be based solely on CDU. Although a significant number of type II endoleaks resolved spontaneously, intervention can be offered for type II endoleaks if associated with an increasing sac size.
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Affiliation(s)
- Ali F AbuRahma
- Vascular Center of Excellence, Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston Area Medical Center, Charleston, West Virginia 25304, USA.
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34
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Stavropoulos SW, Kim H, Clark TWI, Fairman RM, Velazquez O, Carpenter JP. Embolization of Type 2 Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysms with Use of Cyanoacrylate with or without Coils. J Vasc Interv Radiol 2005; 16:857-61. [PMID: 15947050 DOI: 10.1097/01.rvi.0000156495.66062.62] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Translumbar embolization was used to treat 11 type 2 endoleaks in nine patients with the liquid embolic agent n-butyl cyanoacrylate (NBCA). Nine of the embolizations were performed with a combination of stainless-steel coils and NBCAJ and the other two were performed with NBCA alone. There was complete occlusion on initial computed tomographic (CT) angiography in six of nine patients (66%), including the two cases treated with NBCA alone. Persistent endoleak on initial CT angiography occurred in three of nine patients (33%). Two of these patients underwent successful repeated embolization with NBCA. Aneurysm size remained unchanged in four patients (44%), decreased in four patients (44%), and increased in one patient (11%). No complications occurred. Initial results with the use of NBCA for endoleak embolization are encouraging.
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Affiliation(s)
- S William Stavropoulos
- Department of Radiology, University of Pennsylvania Medical Center, 3400 Spruce Street, Philadelphia, PA 19010, USA.
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Mousa A, Dayal R, Bernheim J, Henderson P, Hollenbeck S, Trocciola S, Prince M, Gordon R, Badimon J, Fuster V, Marin ML, Kent KC, Faries PL. A canine model to study the significance and hemodynamics of type II endoleaks1. J Surg Res 2005; 123:275-83. [PMID: 15680390 DOI: 10.1016/j.jss.2004.08.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2004] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The clinical significance of Type 2 endoleak after endovascular repair of abdominal aortic aneurysms (AAA) remains incompletely delineated. This study describes the development of a novel canine model that allows for continuous monitoring of intraaneurysmal pressure in the setting of Type 2 endoleak. METHODS Infrarenal AAA were created in 10 mongrel dogs by implanting a prosthetic aneurysm containing an intraluminal, solid-state, strain gauge pressure transducer which is able to measure pressures in both solid and liquid media. A segment of native aorta with two or more patent side branch vessels was reimplanted into the prosthetic aneurysm using a Carrel patch. Four animals had two lumbar vessels implanted; two had two lumbar vessels and the caudal mesenteric artery implanted, and four control animals had no vessels reimplanted. Retrograde flow in the aneurysmal side branches caused a Type 2 endoleak after the aneurysm was excluded from antegrade flow by deploying a stent graft. Both systemic and intra-sac pressures were measured daily for up to 90 days after endovascular exclusion and indexed to systemic pressure. Endoleak patency and flow were assessed with digital subtraction angiography, duplex ultrasound, and cine-magnetic resonance angiography (MRA). Histological characterization of the intraaneurysmal contents was performed. RESULTS Before endovascular exclusion, the systolic, mean arterial, and pulse pressure within the aneurysmal sac closely matched that of the systemic circulation (systolic, 0.96 +/- 0.22; mean, 0.94 +/- 0.21; pulse pressure, 0.97 +/- 0.22) (R value, 0.97). Endovascular exclusion in animals with no collateral side branch vessels resulted in no endoleak and significantly reduced intraaneurysmal pressure when compared to systemic pressure, with systolic, mean arterial, and pulse pressure 0.172 +/- 0.05, 0.137 +/- 0.05, and 0.098 +/- 0.02, respectively (P < 0.001). In animals with Type 2 endoleaks, the pressures were lower than systemic pressure, but statistically significant in their difference from the control group. The systolic pressure of those with Type 2 endoleaks was 0.702 +/- 0.048; mean arterial pressure was 0.784 +/- 0.028, and pulse pressure was 0.406 +/- 0.031 when indexed to systemic pressure (P < 0.001). Cine-MRA and Duplex ultrasound documented persistent patency of the Type 2 endoleaks throughout the study period in animals with multiple side branches. CONCLUSION Intraaneurysmal pressure in the setting of Type 2 endoleaks may be accurately determined using this canine model. Intraaneurysmal pressure is maintained at a significant level in the context of this retrograde collateral perfusion, suggesting that persistent Type 2 endoleaks are of clinical significance. This model may serve to allow further evaluation and characterization of Type 2 endoleaks.
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Affiliation(s)
- Albeir Mousa
- Department of Surgery, New York Presbyterian Hospital, Cornell University, Weill Medical College, Columbia University, College of Physicians and Surgeons, New York, New York, USA
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Abstract
Endovascular aneurysm repair has proven to be a valuable alternative to open repair in selected patients. This less invasive procedure, however, requires long-term surveillance for its own set of potential complications, including perigraft leakage, or endoleak. This article focuses on the detection of these leaks, first defining and classifying endoleaks and then describing various means of detecting them, including computed tomographic angiography, magnetic resonance angiography, color-flow duplex ultrasonography, and conventional angiography.
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Affiliation(s)
- Mark D Hiatt
- Department of Radiology, Stanford University Medical Center, Stanford, CA 94305-5105, USA
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37
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Sheehan MK, Barbato J, Compton CN, Zajko A, Rhee R, Makaroun MS. Effectiveness of coiling in the treatment of endoleaks after endovascular repair. J Vasc Surg 2004; 40:430-4. [PMID: 15337869 DOI: 10.1016/j.jvs.2004.06.034] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Persistent endoleaks are a common problem following endovascular repair of abdominal aortic aneurysms, and the best method of treatment has been an issue of debate. Some experimental evidence has suggested that coiling may not be an effective method because it allows transmission of pressure across the coils with continued expansion of the sac. We reviewed our experience with endoleak coiling to assess the degree of clinical success of this treatment. METHODS A retrospective review of patients with type I or type II endoleaks treated solely by coiling over a 7-year period (1997-2003) was performed. All endoleaks had been observed for at least 6 months prior to intervention to detect spontaneous resolution. All coils were delivered by selective catheterization of the endoleaks. For Type II endoleaks, the branches were all coiled at their junction with the sac when feasible and the endoleak cavity was packed. Clinical success was defined as cessation of endoleak on follow-up computed tomography as well as no further aneurysmal growth (> or =5mm minor axis). RESULTS Twenty-eight patients had their endoleaks treated only with coils. There were 22 Ancure, 2 Excluder, 2 AneuRx, and 2 Lifepath endografts in this patient cohort. Procedural morbidity was 0%. Mean follow-up after coiling for all patients was 18 months (range, 1-60 months) while mean follow-up for patients with a type I endoleak was 24 months. Clinical success was achieved in 15 of 19 (79%) patients with type II endoleaks and 8 of 9 (89%) patients with type I. Three patients, all with type I endoleak, required more than 1 episode of coiling, while 2 others, both with type II lumbar endoleaks, required repeat angiography due to inability to access the leak during the first attempt. There were 2 proximal and 6 distal type I endoleaks (2 aortic, 6 iliac) successfully treated while the type II successes included 8 inferior mesenteric artery and 7 sole lumbar endoleaks. Five patients continued to show evidence of endoleak over time: 2 endoleaks were associated with aneurysm growth leading to conversion in 1 patient, 2 patients with type II endoleaks are stable, and the sole type I endoleak with continued perigraft flow has shown significant shrinkage of the sac and continues to be observed 18 months later. No ruptures were noted during follow-up. CONCLUSION Coiling as the sole method of endoleak management may be a suitable treatment option in selected patients. Clinical success can be expected in over 80% of patients with type II and select type I endoleaks, with minimal morbidity.
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Affiliation(s)
- Maureen K Sheehan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, PA 15213, USA
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Abstract
BACKGROUND Endovascular repair of abdominal aortic aneurysm has become widely used. Supporters claim high success rates, few complications and a dramatically reduced hospital stay. However, endoleak, endotension and reports of endoprosthesis rupture are causes of concern. METHODS A Medline search was undertaken to identify articles on endovascular repair of abdominal aortic aneurysm. Additional papers were identified by manual scanning of the references from key articles. RESULTS AND CONCLUSION Endoleak is a potentially serious complication of the endovascular technique and occurs in a significant proportion of patients. It is still not possible to judge whether the presence of an endoleak alone signifies failure of treatment, and the long-term durability of prosthetic covered stents is unknown. However, endovascular repair does appear to confer a degree of protection from rupture although patients must be advised of the need for life-long imaging surveillance and, perhaps, further intervention.
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Affiliation(s)
- T J Gorham
- Radiology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Corriere MA, Feurer ID, Becker SY, Dattilo JB, Passman MA, Guzman RJ, Naslund TC. Endoleak following endovascular abdominal aortic aneurysm repair: implications for duration of screening. Ann Surg 2004; 239:800-5; discussion 805-7. [PMID: 15166959 PMCID: PMC1356288 DOI: 10.1097/01.sla.0000128300.60156.ab] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Endovascular abdominal aortic aneurysm repair (EAR) requires long-term surveillance for endoleak or increase in aneurysm diameter. We analyzed the natural history of and risk factors for endoleak development. SUMMARY BACKGROUND DATA Endoleak is a common complication of EAR that can lead to aneurysm enlargement and even rupture. Following EAR, imaging studies are used to identify leaks since patients with endoleak may require additional endovascular interventions or conversion to open repair. No criteria currently exist for cessation or reduction in frequency of screening imaging studies. METHODS Data on 220 patients undergoing EAR were retrospectively reviewed. Kaplan-Meier survival analysis and Cox proportional hazards regression were used with the end point being new endoleak development. Potential risk factors included preoperative aneurysm diameter, number of negative surveillance studies, and postoperative increase in diameter. RESULTS A total of 52 patients (24%) who underwent EAR had endoleak detected during postoperative follow-up, which averaged 19 months (range, 0.4-101 months). One, 6-, 12-, and 24- month endoleak-free survival was 90%, 80%, 77%, and 73%, respectively. Three leaks occurred after year 2, at postoperative months 24, 48, and 85. Increasing number of negative screening studies was negatively associated with risk for endoleak development (B = -3.122, P < 0.001), while increase in aneurysm diameter was positively associated with risk for endoleak (B = 0.072, P = 0.04). CONCLUSION Risk for endoleak declines as the number of negative postoperative scans increases, but new endoleaks are identified as late as 7 years following EAR. Reduction in screening frequency cannot be uniformly recommended at this time. Patients with documented aneurysm expansion should be monitored carefully and endoleak should be suspected.
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Affiliation(s)
- Matthew A Corriere
- Division of Vascular Surgery and Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Stavropoulos SW, Carpenter JP, Fairman RM, Golden MA, Baum RA. Inferior vena cava traversal for translumbar endoleak embolization after endovascular abdominal aortic aneurysm repair. J Vasc Interv Radiol 2004; 14:1191-4. [PMID: 14514813 DOI: 10.1097/01.rvi.0000085771.71254.14] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
When embolization of a collateral (type II) endoleak after endovascular repair of an abdominal aortic aneurysm is indicated, endoleak embolization with a translumbar approach is often the procedure of choice. Because of the position of the endoleak, it is sometimes necessary to use a right-sided translumbar approach and traverse the inferior vena cava when accessing the endoleak. Twelve type II endoleaks in nine patients were treated with transcaval translumbar embolization during a 34-month period. No clinically significant hemorrhage occurred. Embolizing type II endoleaks with a right translumbar approach is feasible. Long-term follow-up with more patients is necessary to fully evaluate the durability of this procedure.
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Affiliation(s)
- S William Stavropoulos
- Division of Interventional Radiology, Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104, USA.
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41
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Greenberg RK, Deaton D, Sullivan T, Walker E, Lyden SP, Srivastava SD, Ouriel K, Ivanc T, Burton T, Mayo J. Variable sac behavior after endovascular repair of abdominal aortic aneurysm: analysis of core laboratory data. J Vasc Surg 2004; 39:95-101. [PMID: 14718825 DOI: 10.1016/j.jvs.2003.08.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The behavior of the aneurysm sac after endovascular grafting has been the subject of significant speculation. The importance of sac behavior is manifested by the correlation between aneurysm size or size change and risk for rupture, and potentially further extrapolated to define the need for secondary intervention. This study was undertaken to define graft-specific differences and the effect of endoleak on sac remodeling. METHODS Core laboratory data were obtained for three US Phase II clinical trials. Patients were included if they met anatomic inclusion criteria and underwent placement of the latest version of a bifurcated endovascular prosthesis. Unsupported Dacron (Ancure), supported Dacron (Zenith), and expanded polytetrafluoroethylene (Excluder) grafts were evaluated. Digitized images were electronically assessed for aneurysm size (area, maximum, minimum diameter) with National Institutes of Health Image software. Two blinded reviewers analyzed each radiographic study to ensure accurate image selection and establish the presence or absence of endoleak. A third reviewer adjudicated discrepancies. chi(2) analysis and mixed nonlinear modeling were used to analyze the results. RESULTS Of 1506 patients evaluated, 723 (227 Ancure, 343 Excluder, 153 Zenith) met inclusion criteria for the study. Mean follow-up was 23.2 months (Ancure, 31.3 months; Excluder, 19.6 months; Zenith, 19.3 months). The incidence of any endoleak was 39.1% (Ancure, 58.1%; Excluder, 34.7%; Zenith, 20.9%; P <.001). Type of prosthesis, presence or absence of endoleak, and baseline size were determinants of rate of aneurysm shrinkage. Reduction in sac size was greatest with the Zenith graft, followed by the Ancure and Excluder grafts. Presence of endoleak had a moderating effect on rate of sac shrinkage with the Zenith and Ancure grafts; however, sac size increased in the presence of endoleak with the Excluder graft. Finally, baseline size was positively correlated with rate of aneurysm shrinkage. CONCLUSIONS The behavior of the aneurysm sac depends on the type of prosthesis, presence or absence of endoleak, and baseline size of the sac. Differential sac behavior must be considered when determining the need for secondary interventions, timing follow-up studies, and assessing success or failure of endovascular repair.
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Affiliation(s)
- Roy K Greenberg
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Desk S-40, 9500 Euclid Avenue, Clevelahd, OH 44195, USA.
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Dillavou ED, Muluk SC, Rhee RY, Tzeng E, Woody JD, Gupta N, Makaroun MS. Does hostile neck anatomy preclude successful endovascular aortic aneurysm repair? J Vasc Surg 2003; 38:657-63. [PMID: 14560209 DOI: 10.1016/s0741-5214(03)00738-9] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Poor outcomes have been reported with endovascular aneurysm repair (EVAR) in patients with hostile neck anatomy. Unsupported endografts with active fixation may offer certain advantages in this situation. We compared EVAR results using the Ancure (Guidant) endograft in patients with and without hostile neck anatomy. METHODS Records of EVAR patients from October 1999 to July 2002 at a tertiary care hospital were retrospectively reviewed from a division database. Patients with elective open abdominal aortic aneurysm (AAA) repair during the same period were reviewed to determine those unsuitable for EVAR. Hostile neck anatomy, assessed by computer tomography (CT) scans and angiograms, was defined as one or more of the following: (1) neck length </=10 mm, (2) focal bulge in the neck >3 mm, (3) >2-mm reverse taper within 1 cm below the renal arteries, (4) neck thrombus > or =50% of circumference, and (5) angulation > or =60 degrees within 3 cm below renals. RESULTS Three hundred and twenty-two patients underwent EVAR with an average follow-up of 18 months. Patients in Phase II trials (n = 41), repaired with other graft types (n = 48), or without complete anatomic records (n = 27) were excluded. Demographics and co-morbidities were similar in the 115 good-neck (GN) and 91 bad-neck (BN) patients except for age (mean, 72.9 years GN vs 75.7 BN; P = 0.13), gender (11% female GN vs 22% BN; P =.04); neck length (mean, 21.8 mm GN vs 14.4 mm BN: P <.001), and angulation (mean, 22 degrees GN vs 40 degrees BN; (P <.001). Perioperative mortality (0 GN vs 1.1% BN), late mortality (5.2% GN vs 4.4% BN), all endoleaks (19.1% GN vs 17.6% BN), proximal endoleaks (0.8% GN vs 2.1% BN), and graft migration (0 for both groups) did not reach statistical significance. Neck anatomy precluded EVAR in 106 of 165 (64%) patients with open AAA. CONCLUSIONS Unsupported endografts with active fixation can yield excellent results in treating many medically compromised patients with hostile neck anatomy. Nonetheless, an unsuitable neck remains the most frequent cause for open abdominal AAA.
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Affiliation(s)
- Ellen D Dillavou
- Division of Vascular Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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Raman KG, Missig-Carroll N, Richardson T, Muluk SC, Makaroun MS. Color-flow duplex ultrasound scan versus computed tomographic scan in the surveillance of endovascular aneurysm repair. J Vasc Surg 2003; 38:645-51. [PMID: 14560207 DOI: 10.1016/s0741-5214(03)00909-1] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of this study is to compare both computed tomographic scan (CT) and color flow duplex ultrasound scanning (CDU) as surveillance modalities for clinically significant endoleaks and to evaluate concordance in abdominal aortic aneurysm (AAA) diameter measurements in patients after endovascular aneurysm repair (EVAR) in a busy hospital vascular laboratory. METHODS We conducted a retrospective review of all patients who underwent endovascular repair of abdominal aortic aneurysms between February 1996 and November 2002 and had same-day CT and CDU studies. Ninety-seven patients enrolled in phase II clinical studies of Ancure devices had long-term follow-up with both modalities. The other patients underwent simultaneous studies, usually only at the 1-month postoperative visit. Peripheral vascular studies were performed by two certified vascular technicians; all CT scans were reviewed by one vascular surgeon. CT was used as the standard against which the sensitivity, specificity, negative predictive value, and positive predictive value of CDU in endoleak detection was determined. Statistics were performed by using the paired t test; a P value <.05 was considered significant. Kappa statistic was used to assess the correlation between CDU and CT in identifying endoleaks. The correlation between CT and CDU in AAA size measurements as well as in serial size measurements was also determined. RESULTS Four hundred ninety-five same-day CT and CDU examinations were reviewed in 281 patients. Patients had an average follow-up of 34.6 months (range, 1 to 72 months). Thirty-five leaks were identified among the patients studied (12.4% overall). In comparison with CT, diagnosis of endoleak with ultrasound scanning was associated with a sensitivity of 42.9%, specificity of 96.0%, positive predictive value of 53.9%, and negative predictive value of 93.9%. The correlation between the two modalities was modest (kappa statistic 0.427). The minor axis transverse diameter as measured by ultrasound and CT scans (4.81 +/- 1.1 cm on CT and 4.55 +/- 1.1 cm on ultrasound) correlated closely (r =.93, P <.001.) Seventy percent of paired studies differed by < or =5 mm. Changes in aneurysm size throughout follow-up were -.29 +/-.71 cm on CT scan -.34 +/-.57 cm on duplex ultrasound scan. The correlation coefficient was.65 (P <.001). There was no significant difference in the change as measured by either modality on the paired t test. CONCLUSIONS Although CDU demonstrates a high degree of correlation with CT scan in determining aneurysm size change over time, it has a low sensitivity and positive predictive value in endoleak detection. In the hospital vascular laboratory at a large tertiary care center, CDU cannot effectively replace CT scan in surveillance after EVAR.
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Affiliation(s)
- Kathleen G Raman
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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Brewster DC, Cronenwett JL, Hallett JW, Johnston KW, Krupski WC, Matsumura JS. Guidelines for the treatment of abdominal aortic aneurysms. Report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery. J Vasc Surg 2003; 37:1106-17. [PMID: 12756363 DOI: 10.1067/mva.2003.363] [Citation(s) in RCA: 508] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Decision-making in regard to elective repair of abdominal aortic aneurysms (AAA) requires careful assessment of factors that influence rupture risk, operative mortality, and life expectancy. Individualized consideration of these factors in each patient is essential, and the role of patient preference is of increasing importance. It is not possible or appropriate to recommend a single threshold diameter for intervention which can be generalized to all patients. Based upon the best available current evidence, 5.5 cm is the best threshold for repair in an "average" patient. However, subsets of younger, good-risk patients or aneurysms at higher rupture risk may be identified in whom repair at smaller sizes is justified. Conversely, delay in repair until larger diameter may be best for older, higher-risk patients, especially if endovascular repair is not possible. Intervention at diameter <5.5 cm appears indicated in women with AAA. If a patient has suitable anatomy, endovascular repair may be considered, and it is most advantageous for older, higher-risk patients or patients with a hostile abdomen or other technical factors that may complicate standard open repair. With endovascular repair, perioperative morbidity and recovery time are clearly reduced; however, there is a higher reintervention rate, increased surveillance burden, and a small but ongoing risk of AAA rupture. There is no justification at present for different indications for endovascular repair, such as earlier treatment of smaller AAA. Until long-term outcome of endoluminal repair is better defined and results of randomized trials available, the choice between endovascular and open repair will continue to rely heavily on patient preference.
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Fan CM, Santilli JG. Endovascular repair of abdominal aortic aneurysms. Semin Roentgenol 2002; 37:282-92. [PMID: 12455126 DOI: 10.1016/s0037-198x(02)80005-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Chieh-Min Fan
- Division of Vascular Radiology, Massachusetts General Hospital, GRB 290, 55 Fruit Street, Boston, MA 02114, USA
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Dattilo JB, Brewster DC, Fan CM, Geller SC, Cambria RP, Lamuraglia GM, Greenfield AJ, Lauterbach SR, Abbott WM. Clinical failures of endovascular abdominal aortic aneurysm repair: incidence, causes, and management. J Vasc Surg 2002; 35:1137-44. [PMID: 12042723 DOI: 10.1067/mva.2002.124627] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Despite well-documented good early results and benefits of endoluminal stent graft repair of abdominal aortic aneurysm (J Vasc Surg 2002;35:1137-44.)(AAA), the long-term outcome of this method of treatment remains uncertain. In particular, concern exists that late effectiveness and durability are inferior to that of open repair. To determine the incidence and causes of clinical failures of endovascular AAA repair, a 7-year experience with 362 primary AAA endografts was reviewed. METHODS Clinical failures were defined as deaths within 30 days of the procedure, conversions (early and late) to open AAA repair, AAA rupture after endoluminal treatment, or AAA sac growth of more than 5 mm in maximal diameter despite endograft repair. Endoleak status per se was not considered unless it resulted in an adverse event. If clinical problems arose but could be corrected with catheter-based therapies or limited surgical procedures, thereby maintaining the integrity of successful stent graft treatment of the AAA, such cases were considered as primary assisted success and not classified as clinical failures. RESULTS The average follow-up period was 1.5 years. Six deaths (1.6%) occurred after the procedure, all in elderly patients or patients at high risk. Five patients (1.4%) needed early conversion (immediate, 2 days) to open repair for access problems or technical difficulties with deployment, resulting in an implantation success rate of 98.6%. Eight patients (2.2%) underwent late conversion for a variety of problems, including AAA expansion (n = 4), endograft thrombosis (n = 1), secondary graft infection (n = 2), and rupture at 3 years (n = 1). Rupture occurred in an additional two patients for a total incidence rate of 0.8%. AAA sac growth of greater than 5 mm was observed in 20 patients (5.6%), four of whom have undergone successful catheter-based treatments to date. Overall, 39 patients (10.7%) needed catheter-based (n = 45) or limited surgical (n = 4) reinterventions for a variety of late problems that were successful in 92%. CONCLUSION In our 7-year experience, one or more clinical failures of endovascular AAA repair were observed in 31 patients (8.3%). Reinterventions were necessitated in a total of 10.7% of patients but were usually successful in maintaining AAA exclusion and limiting AAA growth. These results emphasize that endovascular repair provides good results and many benefits for most properly selected patients but is not as durable as standard open repair.
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Affiliation(s)
- Jeffery B Dattilo
- Division of Vascular Surgery, Massachusetts General Hospital and Harvard Medical School, One Hawthorne Place, Boston, MA 02114, USA
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Carpenter JP. Regarding: "The incidence and natural history of type I and II endoleak: a 5-year follow-up assessment with color duplex ultrasound scan". J Vasc Surg 2002; 35:595-7. [PMID: 11877715 DOI: 10.1067/mva.2002.121849] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jeffrey P Carpenter
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, USA.
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48
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Parent FN, Meier GH, Godziachvili V, LeSar CJ, Parker FM, Carter KA, Gayle RG, DeMasi RJ, Marcinczyk MJ, Gregory RT. The incidence and natural history of type I and II endoleak: a 5-year follow-up assessment with color duplex ultrasound scan. J Vasc Surg 2002; 35:474-81. [PMID: 11877694 DOI: 10.1067/mva.2002.121848] [Citation(s) in RCA: 143] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose of this study was the demonstration of the value of color duplex ultrasound (CDU) scanning in the detection of type I endoleak (T1EL) and type II endoleak (T2EL), the correlation of Doppler scan waveform pattern to endoleak persistence or seal, and the description of the natural history of endoleak. METHODS The study was a retrospective review of 83 patients who underwent periodic CDU scan and computed tomographic (CT) scan surveillance of the endograft and aneurysm sac after insertion of an aortic endograft for abdominal aortic aneurysm (AAA). Forty-one patients (49%) with an endoleak at anytime in the follow-up period form the basis of this report. RESULTS T1EL was detected in all five patients with CDU and CT scans. T2EL was detected in 36 patients with CDU scan as compared with 18 patients with CT scan. With CT scan, endoleak was not detected when CDU scan showed no endoleak. Conversely, all CT scan--detected endoleaks were found with CDU scanning. The T2EL source artery was identified with CT scan in seven patients, whereas the source was identified in all 36 patients with CDU scan. Endoleak source did not correlate with outcome (seal or persistence). However, a to/fro Doppler scan waveform pattern was associated with spontaneous T2EL seal in seven of 12 patients, and a monophasic or biphasic waveform was associated with endoleak persistence in 14 of 17 patients (P =.023, with chi(2) test). Thirteen of 36 T2ELs underwent spontaneous seal by 6.2 +/- 2.8 months. T2ELs without increasing AAA diameter were observed. Eight patients with persistent T2EL present for more than 12 months did not undergo treatment. However, two patients underwent T2EL obliteration with coils because of AAA sac enlargement. T1EL of the distal attachment site was the initial endoleak identified in five patients, but seven patients harboring T2ELs had subsequent T1ELs develop. For the entire 83 patients, the combined T1EL and T2EL prevalence rate was 20% of patients at a 6-month follow-up period, but this rate increased to 50% after 24 months. The incidence rate of newly detected endoleaks and of spontaneous sealing was 24.4% at 12 months and 12.5% in longer-term follow-up period. CONCLUSION CDU scan is effective in the identification of the type of endoleak, the delineation of the vessel involved, and the hemodynamic information not available with any other testing method. Endoleaks have a dynamic natural history characterized by a variable onset with changing branch vessel involvement and spectral flow patterns. Periodic long-term endograft surveillance with CDU scanning is necessary for following existing endoleaks and for detecting new ones. Corroboration of these findings in larger multicenter prospective trials will be needed to determine whether CDU scan analysis of endoleaks would be predictive of long-term success in endovascular AAA repair.
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Carpenter JP, Baum RA, Barker CF, Golden MA, Velazquez OC, Mitchell ME, Fairman RM. Durability of benefits of endovascular versus conventional abdominal aortic aneurysm repair. J Vasc Surg 2002; 35:222-8. [PMID: 11854718 DOI: 10.1067/mva.2002.120034] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Endovascular abdominal aortic aneurysm (AAA) repair is reported to result in less initial patient morbidity and a shorter hospital length of stay (LOS) when compared with conventional AAA repair. We sought to examine the durability of this result during the intermediate follow-up interval. METHODS The records of all admissions for all patients who underwent AAA repair during a 26-month interval were reviewed. RESULTS Three hundred thirty-seven (337) patients underwent procedures to repair AAAs (163 open and 174 endovascular). Endovascular procedures were performed with a variety of devices (Talent, 108; Ancure, 36; AneuRx, 26; Zenith, 2; and Cordis, 2) and configurations (141 bifurcated and 33 aortomonoiliac). The mean follow-up period was 10.6 months (endovascular repair) and 12.3 months (open repair). LOS did not significantly vary by device (P =.24 to P =.92) or configuration (P =.24). The initial median LOS for procedures was significantly shorter (P =.009) for endovascular repairs (5 days) than for open procedures (8 days). However, the patients who underwent endovascular repair were more likely to be readmitted during the follow-up interval when compared with patients who underwent open procedure. The readmission-free survival rate after AAA repair at 12 months was 95% for patients for open AAA repair versus 71% for patients for endovascular repair (P <.001). If the total hospital days were compared, including the initial and all subsequent AAA-related admissions, there was no significant difference for mean LOS for patients who underwent endovascular versus open AAA procedures (11 days versus 13.6 days; P =.21). The patients for endovascular AAA repair most commonly needed readmission for treatment of endoleak (n = 31), wound infection (n = 12), and graft limb thrombosis (n = 9). Although women had similar LOS to men for endovascular repair (P =.44), they had longer initial LOS for open AAA repair (15 versus 10 days; P =.03). After endovascular repair, women were more likely than men to be readmitted by 12 months (51% versus 71% readmission-free survival rate; P =.03) and they had longer LOS on readmission (13.2 versus 5.2 days; P =.006). No gender differences were identified for patients after open AAA repair regarding readmission-free survival rate (P =.09) or LOS on readmission (P =.98). CONCLUSION Although initial LOS was shorter for the patients who underwent endovascular as compared with conventional AAA repair, this advantage was lost during the follow-up interval because of frequent readmission for the treatment of procedure-related complications, chiefly endoleak. These readmissions frequently involved the performance of additional invasive procedures. Gender differences existed regarding LOS and the likelihood of complications after open and endovascular AAA repair.
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Affiliation(s)
- Jeffrey P Carpenter
- Department of Surgery, University of Pennsylvania School of Medicine, PA, USA.
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50
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Walschot LHB, Laheij RJF, Verbeek ALM. Outcome after endovascular abdominal aortic aneurysm repair: a meta-analysis. J Endovasc Ther 2002; 9:82-9. [PMID: 11958330 DOI: 10.1177/152660280200900114] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To determine the frequencies of complications and risk factors for complications following endovascular abdominal aortic aneurysm (AAA) repair (EVAR). METHODS Thirty-nine articles published between October 1995 and October 1999 in English, German, French, or Dutch were identified in electronic databases. All articles reported perioperative (30-day) complications on 2387 patients, while postoperative complications (>30 days) were reported on 1645 patients in 30 of 39 studies. Data were pooled and subjected to multivariable logistic regression analysis to identify risk factors for death, endoleak, rupture, conversion, and local and systemic complications. Effects of risk factors were expressed as odds ratios (OR) with 95% confidence interval (CI). RESULTS Mean follow-up was 13.9 months (range 4-29). The perioperative death rate (3.7%) was lower than postoperative mortality (5.0% per annum). The risks for both endoleak (13.1%) and conversion (5.0%) were higher in the perioperative period than postoperatively (5.4% and 1.4% per annum, respectively). Independent risk factors for perioperative complications were: general anesthesia (death: OR = 5.1, 95% CI 1.9-13.3); EVT graft (endoleak: OR = 3.0, 95% CI 1.3-7.0); female sex (rupture: OR = 2.8, 95% CI 1.4-5.8); hypertension (conversion: OR = 0.03, 95% CI 0.0-0.3); age >70 years (conversion: OR = 3.5, 95% CI 1.3-9.2); and team experience >30 patients (conversion: OR = 3.0, 95% CI 1.2-1.6). Independent risk factors for postoperative complications were: predischarge examination (death: OR = 0.2, 95% CI 0.0-0.7); follow-up 30 days after operation (death: OR = 0.3, 95% CI 0.1-1.0); and female sex (rupture: OR = 1.4, 95% CI 0.5-4.4; conversion: OR 6.8, 95% CI 2.0-23.4; and systemic complications: OR = 2.9, 95% CI 1.1-7.5). CONCLUSIONS The risk of complications after EVAR is high, supporting the cautious use of EVAR. Both patient characteristics and procedural variables were independent risk factors for complications. To avoid the limitations of this study, the results of randomized clinical trials must determine if EVAR offers a safe and durable alternative to open AAA repair.
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Affiliation(s)
- Luc H B Walschot
- Department of Epidemiology, UMC St. Radboud, Nijmegen, The Netherlands
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