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Becker D, Riggi M, Wyss TR, Jungi S, Weiss S, Kotelis D, Schmidli J, Bosiers MJ, Makaloski V. Indication and Outcome of Late Open Conversion after Abdominal Endovascular Aortic Repair. Ann Vasc Surg 2024; 106:196-204. [PMID: 38810725 DOI: 10.1016/j.avsg.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/20/2024] [Accepted: 02/24/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) has become the standard of care for patients with infrarenal aortic aneurysms over the last 2 decades. Endograft technology and treatment of complications like endoleaks, graft migration, or graft occlusion developed over time. However, sometimes open surgical conversion maybe required. Our aim was to analyze the indications, the technical aspects and outcomes in patients who underwent open conversion after EVAR with different types and generations of endografts. METHODS This retrospective single-center study reviewed all patients who underwent EVAR from 2004 to 2020. Open surgical conversions >1 month post EVAR were identified. Conversions for graft infection were excluded. Indications for conversion and operative technique were analyzed. Primary endpoint of the study was 30-day mortality. Secondary endpoints were re-interventions and follow-up mortality. RESULTS During 2004 and 2020, 443 consecutive EVARs were performed, and 28 patients required open surgical conversion, with an additional 3 referred from other hospitals (N = 31). The median age was 75 (range 58-93); 94% were male. Conversion was performed after a median time of 55 months (range 16-209). Twenty patients underwent elective and 11 emergency conversion. Indications for open conversion were graft migration, respectively, disease progression with endoleak type Ia and/or Ib in 52% (16/31) and sac expansion due to endoleak type II in 26% (8/31). Of the 31 patients, 17 (55%) had at least one previous endovascular re-intervention. All patients met the device-specific instructions for use for each implanted endograft. In-hospital intervention rate was 16% (5/31). Thirty-day mortality rate was 3% (1/31) with one patient died due to multiorgan failure after rupture with complete endograft replacement. Five patients (16%) died during follow-up. Mid-term follow-up was 47.5 months (range 24-203) with estimated cumulative survival rates of 97%, 89%, and 84%, at 1, 3, and 5 years, respectively. CONCLUSIONS Late open conversion remains a valuable treatment option and can be performed safely in elective and emergency setting with a low early mortality. Lifelong surveillance and prompt intervention when necessary are essential in ensuring optimal outcomes after EVAR and preventing the need for emergent conversions.
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Affiliation(s)
- Daniel Becker
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Manuela Riggi
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Rudolf Wyss
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Interventional Radiology and Vascular Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Silvan Jungi
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Salome Weiss
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drosos Kotelis
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürg Schmidli
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michel Joseph Bosiers
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024:ehae179. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Paajanen P, Karjalainen J, Jaroma M, Tarkiainen M, Manninen H, Mäkinen K, Kärkkäinen J, Saari P. Friendly Neck Anatomy Does Not Prevent Neck-Related Adverse Events After EVAR. Ann Vasc Surg 2024; 104:71-80. [PMID: 37454900 DOI: 10.1016/j.avsg.2023.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/12/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Life-long follow-up after endovascular aneurysm repair (EVAR) is costly and burdensome to the patient. Follow-up should be stratified based on the risk of EVAR failure. Aneurysm neck is thought to be the single most important risk factor. This study investigated neck anatomy as a predictor of neck-related adverse events after EVAR. METHODS This retrospective single-center study included consecutive patients undergoing elective EVAR for infrarenal abdominal aortic aneurysms between 2011 and 2016 (n = 222) who were followed with yearly imaging until December 2020. Hostile neck was defined as neck length ≤15 mm, width ≥28 mm, angulation ≥60°, calcification, or thrombus ≥50% of circumference or conical neck based on preoperative computed tomography angiography. Neck-related adverse event was defined as aneurysm rupture, any neck-related reintervention or type 1a endoleak during follow-up. RESULTS Ninety (41%) patients had hostile neck and 132 (59%) had friendly neck. There were no differences in 30-day mortality (1% vs. 1%, P = 0.78), major adverse events (20% vs. 16%, P = 0.43) or reinterventions during the hospital stay (8% vs. 4%, P = 0.20) between patients with hostile and friendly neck. Estimated survival at 1 year was 89 ± 3% for hostile neck and 95 ± 2% for friendly neck patients (P < 0.01). Five-year survival estimates were 51 ± 6% and 66 ± 4%, respectively. Aneurysm-related mortality was higher after 6 years in patients with hostile neck (P < 0.01). Twenty-four patients (11%) suffered neck-related adverse events with mean time-to-event of 3.3 ± 2.8 years; there were no differences between the groups stratified by neck anatomy. Incidentally, preoperative aneurysm diameter was found to be an independent risk factor for neck-related adverse events and aneurysm-related mortality; 53 patients (24%) had aneurysm diameter ≥70 mm, which was associated with nearly 4-fold risk of neck-related complications during the follow-up. CONCLUSIONS Friendly neck anatomy may not protect from neck-related adverse events after EVAR in the long-term. Especially patients with large aneurysms should be followed closely.
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Affiliation(s)
- Paavo Paajanen
- Heart Center, Kuopio University Hospital, Kuopio, Finland; University of Eastern Finland, Kuopio, Finland.
| | | | | | - Mika Tarkiainen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Hannu Manninen
- University of Eastern Finland, Kuopio, Finland; Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Kimmo Mäkinen
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | | | - Petri Saari
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
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Banks CA, Slay L, Williams BR, Sargent E, Alabi O, Jackson EA, Spangler E. Exploring how military culture shapes veterans' perception of aortic aneurysm repair: A qualitative study. Vascular 2024:17085381241262130. [PMID: 38877806 DOI: 10.1177/17085381241262130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024]
Abstract
BACKGROUND Veterans represent a distinct cultural group whose perceptions of illness and treatment are influenced by military culture. The study explores how prior military service shapes Veterans' assumptions and behaviors in the setting of aneurysm repair surgery. STUDY DESIGN We conducted content and thematic analysis of a case series of 10 transcripts from telephone interviews with older (76.7 ± 4.3 years) African American and White male Veterans now residing in the Southern U.S. who underwent open or endovascular aneurysm surgery at Veterans Affairs Medical Centers or university affiliates between 2004 and2019. RESULTS Throughout the continuum of care, Veterans described deferring to authority and not questioning provider's decisions ["I just can't make a judgment on that, because I'm not a doctor"]. Veterans valued commitment and articulated pride in keeping logistically challenging surveillance appointments [I always took them very seriously. . . If I'm scheduled for something by the doctor, I always make it."]. The routine structure of VA care aligned with Veterans military experiences, facilitating compliance with doctor's orders. However, procedural deviations in VA care were disconcerting for patients ["They haven't reached out to me in at least three years, since my surgery; I was being seen once a year and then all of a sudden, they just quit."]. While Veterans praised VA care, they exhibited sensitivity to signs of untoward treatment from clinical and support staff "…my surgeon, he never talked to me before, nor after, no anytime…I thought that maybe that wasn't right". CONCLUSIONS Military culture embodies rank, order, and respect, and remains a source of strength and stability for Veterans in their medical care late in life. Cultural competency about how military service has shaped Veterans' expectations can enhance providers' awareness of patients' military mindsets and inform surgeons' efforts to engage Veterans in shared decision making.
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Affiliation(s)
- C Adam Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL, USA
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Laurie Slay
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Beverly R Williams
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
- Geriatrics, and Palliative Care, University of Alabama Division of Gerontology, Birmingham, AL, USA
| | - Emily Sargent
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Olamide Alabi
- School of Medicine Division of Vascular Surgery and Endovascular Therapy, Emory University, Atlanta, GA, USA
- Atlanta VA Healthcare System, Atlanta, GA, USA
| | - Elizabeth A Jackson
- Cardiovascular Quality and Outcomes, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Emily Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL, USA
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
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Moulakakis KG, Lazaris AM, Georgiadis GS, Kakkos S, Papavasileiou VG, Antonopoulos CN, Papapetrou A, Katsikas V, Klonaris C, Geroulakos G. A Greek Multicentre Study Assessing the Outcome of Late Rupture After Endovascular Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2024; 67:756-764. [PMID: 38154499 DOI: 10.1016/j.ejvs.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 11/02/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Late rupture after endovascular aortic aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) is an increasing complication associated with a high mortality rate. This study aimed to analyse the causes and outcomes in patients with AAA rupture after EVAR. METHODS A multi-institutional Greek study of late ruptures after EVAR between 2008 - 2022 was performed. Primary outcomes were intra-operative and in hospital death. RESULTS A total of 70 patients presented with late rupture after EVAR (proportion of ruptured EVARs among all EVARs, 0.6%; 69 males; mean age 77.2 ± 6.7 years). The mean time interval between EVAR and late rupture was 72.3 months (range 6 - 180 months). In all cases the cause of rupture was the presence of an endoleak (type I, 73%) with sac enlargement. Moreover, 34% of subjects with rupture after EVAR had been lost to follow up and 32% underwent a secondary intervention. Additionally, 57 patients (81%) were treated by conversion to open surgical repair (COSR) and the remainder by endovascular correction of endoleak (ECE). Eleven intra-operative deaths (16%) were recorded. The overall in hospital mortality rate was 41% (23% ECE vs. 46% COSR; p = .21). Of the patients who presented as initially haemodynamically stable, 23% died during hospitalisation, while the respective mortality rate for patients who presented as unstable was 78% (odds ratio [OR] 11.8, 95% confidence interval [CI] 3.6 - 39.1; p < .001). Multivariable logistic regression analysis revealed that severity of haemodynamic shock was the most significant risk factor for intra-operative (OR 7.15, 95% CI 1.58 - 32.40; p = .010) and in hospital death (OR 9.53, 95% CI 2.79 - 32.58; p < .001). CONCLUSION These data underline the devastating prognosis of late rupture after EVAR. Haemodynamic status at presentation was an important predictive factor for death both in the ECE and COSR groups. Rigorous follow up and prompt evaluation of an unstable patient in case of rupture after EVAR is recommended.
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Affiliation(s)
- Konstantinos G Moulakakis
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, University of Patras Medical School, Patras, Greece.
| | - Andreas M Lazaris
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Stavros Kakkos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | | | - Constantine N Antonopoulos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasios Papapetrou
- Hellenic Vascular Registry (HEVAR); Vascular Surgery Clinic, K.A.T. General Hospital, Athens, Greece
| | - Vasilios Katsikas
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Gennimatas General Hospital of Athens, Athens, Greece
| | - Chris Klonaris
- Hellenic Vascular Registry (HEVAR); 2nd Department of Vascular Surgery, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - George Geroulakos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Zuidema R, van Sambeek MRHM, Zwetsloot J, Heyligers JMM, Pratesi G, Reijnen MMPJ, de Vries JPPM, Schuurmann RCL. Geometric Analysis of the Gore Excluder Conformable Endoprosthesis in the Infrarenal Aortic Neck: One Year Results of the EXCeL Registry. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00362-9. [PMID: 38670221 DOI: 10.1016/j.ejvs.2024.04.026] [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: 11/08/2023] [Revised: 04/01/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVE The Gore Excluder Conformable Endoprosthesis (CEXC) is designed to treat challenging infrarenal anatomy because of its active angulation control, repositionability, and enhanced conformability. This study evaluated 30 day and one year position and apposition of the CEXC in the infrarenal neck. METHODS Patients treated with the CEXC between 2018 and 2022 with an available 30 day computed tomography angiogram (CTA) were selected from four hospitals in a prospective registry. Endograft apposition (shortest apposition length [SAL]) and position (shortest fabric distance [SFD]) were assessed on the 30 day and one year CTAs. Maximum infrarenal aortic curvature was compared between the pre- and post-operative CTAs to evaluate conformability of the CEXC. RESULTS There were 87 patients with a 30 day CTA, and for 56 of these patients the one year CTA was available. Median (interquartile range [IQR]) pre-operative neck length was 22 mm (IQR 15, 32) and infrarenal angulation was 52° (IQR 31, 72). Median SAL was 21.2 mm (IQR 14.0, 29.3) at 30 days for all included patients. The SAL in 13 patients (15%) was < 10 mm at 30 days, and one patient had a SAL of 0 mm and a type Ia endoleak. There was no significant difference in SAL between patients within and outside instructions for use. The SAL significantly increased by 1.1 mm (IQR -2.3, 4.7; p = .042) at one year. The SAL decreased in seven patients (13%), increased in 13 patients (23%), and remained stable in 36 patients (64%). Median SFD was 2.0 mm (IQR 0.5, 3.6) at 30 days, which slightly increased by 0.3 mm (IQR -0.5, 1.8; p = .019) at one year. One patient showed migration (SFD increase ≥ 5 mm). Median endograft tilt was 15.8° (IQR 9.7, 21.4). Pre-operative maximum infrarenal curvature was 36 m-1 (IQR 26, 56) and did not significantly change thereafter. CONCLUSION In most patients, the CEXC was implanted close to the renal arteries, and sufficient (≥ 10 mm) post-operative apposition was achieved at 30 days, which slightly increased at one year. Post-operative endograft tilt was relatively low, and aortic geometry remained unchanged after implantation of the CEXC, probably due to its high conformability.
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Affiliation(s)
- Roy Zuidema
- Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, Groningen, the Netherlands.
| | - Marc R H M van Sambeek
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, the Netherlands; and Department of Biomedical Technology, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Jenny Zwetsloot
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, the Netherlands; and Department of Biomedical Technology, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Jan M M Heyligers
- Department of Vascular Surgery, Elisabeth TweeSteden Hospital, Tilburg, the Netherlands
| | - Giovanni Pratesi
- Department of Surgical and Integrated Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy; and Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Michel M P J Reijnen
- Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands; and Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Jean-Paul P M de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Richte C L Schuurmann
- Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, Groningen, the Netherlands
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Haidar H, Kapahnke S, Frese JP, Omran S, Mueller V, Hinterseher I, Sommerfeld M, Kaschina E, Konietschke F, Greiner A, Buerger M. Risk factors for elective and urgent open conversion after EVAR-a retrospective observational study. Vascular 2024; 32:243-253. [PMID: 36413465 PMCID: PMC11129523 DOI: 10.1177/17085381221141118] [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] [Indexed: 02/17/2024]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) has become the standard procedure for treating infrarenal abdominal aortic aneurysms (AAA). Various associated complications can lead to open conversion (OC). Thorough follow-up after the procedure is mandatory for the early detection of complications. Persisting perfusion of the aneurysm, a so-called endoleak (EL), paired with structural instability because of aortic wall atrophy and impaired cell functionality induced by EVAR, results in a high risk for aortic rupture. PURPOSE The goal of this study was to detect the risk factors for elective and urgent OC as a result of EVAR-induced pathophysiological changes inside the aortic wall. RESEARCH DESIGN Retrospective data analysis was performed on all open aortic repairs from January 2016 to December 2020. DATA COLLECTION AND ANALYSIS Fifty patients were identified as treated by OC for failure of an infrarenal EVAR. The patients were divided into two subgroups, here depending on the urgency of surgery. Statistical analysis of patient characteristics and outcomes was performed. RESULTS The most common indications for OC were various types of EL (74%), resulting in an aortic rupture in 15 patients. Patients with insufficient or absent follow-up were treated more frequently in an emergency setting (16% vs. 63%). The mortality rate was higher in cases of emergency OC (3% vs. 26%). CONCLUSIONS Particularly in cases of insufficient or absent follow-up, complications such as EL pose an enormous risk for fatal aortic rupture.
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Affiliation(s)
- Haidar Haidar
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Sebastian Kapahnke
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Jan P Frese
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Safwan Omran
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Verena Mueller
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Irene Hinterseher
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Germany
| | - Manuela Sommerfeld
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pharmacology, Center for Cardiovascular Research (CCR), Berlin, Germany
| | - Elena Kaschina
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Pharmacology, Center for Cardiovascular Research (CCR), Berlin, Germany
| | - Frank Konietschke
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, Institute of Medical Biometrics and Clinical Epidemiology and Berlin Institute of Health (BIH), Berlin, Germany
| | - Andreas Greiner
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Matthias Buerger
- Department of Vascular Surgery, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Geraedts AC, Zuidema R, Schuurmann RC, Kwant AN, Mulay S, Balm R, de Vries JPP. Shortest Apposition Length at the First Postoperative Computed Tomography Angiography Identifies Patients at Risk for Developing a Late Type Ia Endoleak After Endovascular Aneurysm Repair. J Endovasc Ther 2024; 31:274-281. [PMID: 36113063 PMCID: PMC10938489 DOI: 10.1177/15266028221120514] [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] [Indexed: 02/18/2024]
Abstract
PURPOSE Imaging surveillance following endovascular aneurysm repair (EVAR) is strictly recommended. This study investigates the value of endograft apposition and position relative to the aortic neck on the first postoperative computed tomography angiography (CTA) in determining patients at risk for a late type Ia endoleak (T1aEL). MATERIALS AND METHODS Patients with a T1aEL after the first postoperative CTA were selected from a consecutive database and matched with uncomplicated controls. Endograft apposition and position, including the shortest apposition length (SAL), were determined on the first postoperative CTA. The SAL is the shortest distance between the proximal endograft fabric and the first slice where circumferential apposition with the aortic wall is lost. Differences in endograft apposition at the first postoperative CTA were compared between groups. Logistic regression analysis identified independent predictors for late T1aEL. RESULTS A total of 32 patients with a late T1aEL were included and matched with 32 uncomplicated controls. Median follow-up after primary EVAR was 62.0 (interquartile range [IQR]: 36.8, 83.5) months in the T1aEL group compared with 47.5 (IQR: 34.0, 79.3) months in the control group; p=0.265. Median preoperative neck diameter was significantly larger in the T1aEL group than in the control group (26.6 [IQR: 24.9, 29.6] mm versus 23.4 [IQR: 22.5, 25.3] mm); p<0.001. Patients in the T1aEL group had a median SAL of 11.6 (IQR: 4.3, 20.5) mm compared with 20.7 (IQR: 13.1, 24.9) mm in the control group; p=0.002. SAL <10mm on the first postoperative CTA (odds ratio [OR]: 9.63, 95% confidence interval [CI]: 1.60-57.99) and larger neck diameter (OR: 1.80, 95% CI: 1.26-2.57) were independent predictors for developing a late T1aEL. CONCLUSION Preoperative neck diameter and SAL on the first postoperative CTA following EVAR are important predictors for the development of a late T1aEL. Patients with a SAL of <10mm had a significantly higher risk of developing a late T1aEL. Future research should determine whether these patients would benefit from reintervention before an actual T1aEL is present. CLINICAL IMPACT Understanding the mechanisms of endovascular aneurysm repair failure is essential to further enhance clinical outcomes. Adequate proximal sealing is necessary to foster freedom from type 1a endoleak. This study demonstrates that the shortest apposition length (SAL) at the first postoperative computed tomography angiography (CTA) is able to identify patients at risk for a late type 1a endoleak. Especially patients with a SAL <10mm are at high risk. Currently, the guidelines advice repeated imaging with CTA in patients with a seal <10mm. Future research should determine whether these patients would benefit from re-intervention before an actual type 1a endoleak is present.
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Affiliation(s)
- Anna C.M. Geraedts
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Roy Zuidema
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Richte C.L. Schuurmann
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Ayla N. Kwant
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Sana Mulay
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jean-Paul P.M. de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
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9
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Chen Y, Wang X, Bi J, Liu Z, Niu F, Zhang X, Dai X. Comparative clinical study of short-term outcomes between table fenestrated and chimney endovascular aneurysm repair for hostile neck aneurysms. Vascular 2024; 32:273-280. [PMID: 36305329 DOI: 10.1177/17085381221135859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
OBJECTIVES Hostile neck abdominal aortic aneurysm (AAA) is challenging for standard endovascular aneurysm repair (EVAR). We sought to compare fenestrated endovascular aneurysm repair (fEVAR) and chimney endovascular aneurysm repair (chEVAR) for hostile neck AAA. METHODS Patients were identified retrospectively. Hostile neck anatomy was defined as a proximal neck length of <15 mm or angulation >60°. The choice of fEVAR or chEVAR was based on neck anatomy and physician preference. Type I endoleak (T1EL) was the primary outcome. Other outcomes included type III endoleak (T3EL), visceral stent occlusion, renal insufficiency, reintervention, and mortality. RESULTS A total of 84 patients were included from April 2012 to December 2021. fEVAR and chEVAR patients were 48 and 36 cases, respectively. Both groups showed similar rate of T1EL, T3EL, visceral stent occlusion, renal insufficiency, reintervention, and mortality. However, chEVAR patients had a more tortuous neck (61.1% vs. 16.7%, p < 0.001), while fEVAR patients had a greater neck size (29.5 ± 6.3 mm vs. 24.5 ± 4.8 mm, p < 0.001) and more reconstructing target arteries (2.2 ± 1.1 vs 1.3 ± 0.6, p < 0.001). CONCLUSIONS fEVAR and chEVAR show similar safe and effective outcomes in well-selected hostile neck. fEVAR might be able to reconstruct multiple visceral arteries, and chEVAR seems justified in patients with poor anatomical suitability for fEVAR.
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Affiliation(s)
- Yonghui Chen
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xuguang Wang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Vascular Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia Autonomous Region, China
| | - Jiaxue Bi
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Zongwei Liu
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Fang Niu
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaoxing Zhang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiangchen Dai
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
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Gedney R, Barksdale C, Wright AS, Genovese EA, Ruddy JM. Hostile neck anatomy contributes to higher rates of reintervention following endovascular aortic repair for ruptured infrarenal abdominal aortic aneurysm. Vascular 2024:17085381241239428. [PMID: 38478714 PMCID: PMC11393178 DOI: 10.1177/17085381241239428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Ruptured abdominal aortic aneurysms (AAA) presenting with hostile neck anatomy can represent a challenge in surgical decision-making. We hypothesized that, patients who require reinterventions have higher rates of compromised neck anatomy at initial presentation and may indicate a need for altered surveillance paradigm. METHODS Patients presenting with ruptured AAA to a single tertiary care institution from 2014 to 2021 were retrospectively reviewed. Those treated with infrarenal EVAR, with no prior aortic surgeries, and with available pre-operative computed tomography (CT) scans were included. Demographics, timing and type of reintervention, follow-up, and survival were collected. CT scans were assessed for hostile neck anatomy via measurements of diameter, length, angle, taper, bulge, calcification, and thrombus. Demographics, comorbidities, and neck anatomy of those with and without reintervention were compared using Fischer's Exact and Student's T-test. Survival was analyzed via Kaplan-Meier and log-rank test. RESULTS Eighty-nine patients were available for analysis, 37 of which met inclusion criteria. Intraoperative death occurred in 3 patients (8.1%) and 1 patient (2.7%) was intraoperatively converted to an open repair. Thirty-day and 1-year survival were 97% and 91%, respectively. The reintervention rate was 30% (n = 10), occurring at a median of 200 days (18-2053 days) after the index operation. All patients requiring reintervention met hostile neck criteria (p = .002) and had a statistically higher number of hostile neck criteria (1.80 vs 0.87, p = .03). Thirty percent (n = 3) of patients that received a reintervention had neck diameter greater than 3 cm, compared to zero patients in the non-reintervention group (p = .022). Proximal reinterventions (n = 5) had statistically higher neck diameters and neck angle compared to the non-reintervention group. CONCLUSION Infrarenal rEVAR is effective at preventing acute mortality despite specific anatomic considerations that may contribute to the higher reintervention rates, and therefore those parameters ought to be considered when following patients in the post-intervention period.
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Affiliation(s)
- Ryan Gedney
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Christian Barksdale
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Antwana Sharee Wright
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Elizabeth A Genovese
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Jean Marie Ruddy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
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Chun JY, de Haan M, Maleux G, Osman A, Cannavale A, Morgan R. CIRSE Standards of Practice on Management of Endoleaks Following Endovascular Aneurysm Repair. Cardiovasc Intervent Radiol 2024; 47:161-176. [PMID: 38216742 PMCID: PMC10844414 DOI: 10.1007/s00270-023-03629-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/19/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Endoleaks represent the most common complication after EVAR. Some types are associated with ongoing risk of aneurysm rupture and necessitate long-term surveillance and secondary interventions. PURPOSE This document, as with all CIRSE Standards of Practice documents, will recommend a reasonable approach to best practices of managing endoleaks. This will include imaging diagnosis, surveillance, indications for intervention, endovascular treatments and their outcomes. Our purpose is to provide recommendations based on up-to-date evidence, updating the guidelines previously published on this topic in 2013. METHODS The writing group was established by the CIRSE Standards of Practice Committee and consisted of clinicians with internationally recognised expertise in endoleak management. The writing group reviewed the existing literature performing a pragmatic evidence search using PubMed to select publications in English and relating to human subjects up to 2023. The final recommendations were formulated through consensus. RESULTS Endoleaks may compromise durability of the aortic repair, and long-term imaging surveillance is necessary for early detection and correct classification to guide potential re-intervention. The majority of endoleaks that require treatment can be managed using endovascular techniques. This Standards of Practice document provides up-to-date recommendations for the safe management of endoleaks.
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Affiliation(s)
- Joo-Young Chun
- St George's University Hospitals NHS Foundation Trust, London, UK.
- St George's University of London, London, UK.
| | - Michiel de Haan
- Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Asaad Osman
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Robert Morgan
- St George's University Hospitals NHS Foundation Trust, London, UK
- St George's University of London, London, UK
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12
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Vanmaele A, Bouwens E, Hoeks SE, Kindt A, Lamont L, Fioole B, Moelker A, Ten Raa S, Hussain B, Oliveira-Pinto J, Ijpma AS, van Lier F, Akkerhuis KM, Majoor-Krakauer DF, Hankemeier T, de Rijke Y, Verhagen HJ, Boersma E, Kardys I. Targeted proteomics and metabolomics for biomarker discovery in abdominal aortic aneurysm and post-EVAR sac volume. Clin Chim Acta 2024; 554:117786. [PMID: 38246209 DOI: 10.1016/j.cca.2024.117786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 12/27/2023] [Accepted: 01/14/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND AND AIMS Abdominal aortic aneurysm (AAA) patients undergo uniform surveillance programs both leading up to, and following surgery. Circulating biomarkers could play a pivotal role in individualizing surveillance. We applied a multi-omics approach to identify relevant biomarkers and gain pathophysiological insights. MATERIALS AND METHODS In this cross-sectional study, 108 AAA patients and 200 post-endovascular aneurysm repair (post-EVAR) patients were separately investigated. We performed partial least squares regression and ingenuity pathway analysis on circulating concentrations of 96 proteins (92 Olink Cardiovascular-III panel, 4 ELISA-assays) and 199 metabolites (measured by LC-TQMS), and their associations with CT-based AAA/sac volume. RESULTS The median (25th-75th percentile) maximal diameter was 50.0 mm (46.0, 53.0) in the AAA group, and 55.4 mm (45.0, 64.2) in the post-EVAR group. Correcting for clinical characteristics in AAA patients, the aneurysm volume Z-score differed 0.068 (95 %CI: (0.042, 0.093)), 0.066 (0.047, 0.085) and -0.051 (-0.064, -0.038) per Z-score valine, leucine and uPA, respectively. After correcting for clinical characteristics and orthogonalization in the post-EVAR group, the sac volume Z-score differed 0.049 (0.034, 0.063) per Z-score TIMP-4, -0.050 (-0.064, -0.037) per Z-score LDL-receptor, -0.051 (-0.062, -0.040) per Z-score 1-OG/2-OG and -0.056 (-0.066, -0.045) per Z-score 1-LG/2-LG. CONCLUSIONS The branched-chain amino acids and uPA were related to AAA volume. For post-EVAR patients, LDL-receptor, monoacylglycerols and TIMP-4 are potential biomarkers for sac volume. Additionally, distinct markers for sac change were identified.
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Affiliation(s)
- Alexander Vanmaele
- Department of Cardiology, Thorax Centre, Cardiovascular Institute, Erasmus MC, Rotterdam, the Netherlands; Department of Vascular Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Elke Bouwens
- Department of Cardiology, Thorax Centre, Cardiovascular Institute, Erasmus MC, Rotterdam, the Netherlands; Department of Vascular Surgery, Erasmus MC, Rotterdam, the Netherlands; Department of Anesthesiology, Erasmus MC, Rotterdam, the Netherlands
| | - Sanne E Hoeks
- Department of Anesthesiology, Erasmus MC, Rotterdam, the Netherlands
| | - Alida Kindt
- Metabolomics and Analytics Centre, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
| | - Lieke Lamont
- Metabolomics and Analytics Centre, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Adriaan Moelker
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Sander Ten Raa
- Department of Vascular Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Burhan Hussain
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands; Department of Radiology, Beatrix hospital, Gorinchem, the Netherlands
| | - José Oliveira-Pinto
- Department of Vascular Surgery, Erasmus MC, Rotterdam, the Netherlands; Department of Angiology and Vascular Surgery, Centro Hospitalar São João, Porto, Portugal; Department of Surgery and Physiology, Faculty of Medicine of Oporto, Porto, Portugal
| | - Arne S Ijpma
- Department of Pathology, Erasmus MC, Rotterdam, the Netherlands
| | - Felix van Lier
- Department of Anesthesiology, Erasmus MC, Rotterdam, the Netherlands
| | - K Martijn Akkerhuis
- Department of Cardiology, Thorax Centre, Cardiovascular Institute, Erasmus MC, Rotterdam, the Netherlands
| | | | - Thomas Hankemeier
- Metabolomics and Analytics Centre, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
| | - Yolanda de Rijke
- Department of Clinical Chemistry, Erasmus MC, Rotterdam, the Netherlands
| | - Hence Jm Verhagen
- Department of Vascular Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Eric Boersma
- Department of Cardiology, Thorax Centre, Cardiovascular Institute, Erasmus MC, Rotterdam, the Netherlands
| | - Isabella Kardys
- Department of Cardiology, Thorax Centre, Cardiovascular Institute, Erasmus MC, Rotterdam, the Netherlands.
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13
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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14
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Jena A, Mishra S, Padhee B, Jena SK, Ghosh N, Padhan P, Rout NK, Sahoo P. Extensive thoracoabdominal aortic aneurysm as initial presentation in Takayasu arteritis: case series and literature review. Eur Heart J Case Rep 2024; 8:ytad627. [PMID: 38179470 PMCID: PMC10766067 DOI: 10.1093/ehjcr/ytad627] [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] [Received: 12/21/2022] [Revised: 11/29/2023] [Accepted: 12/13/2023] [Indexed: 01/06/2024]
Abstract
Background Aortic aneurysm as a presenting feature in Takayasu's arteritis is very rare. Here, we report three cases of extensive thoracoabdominal aortic aneurysm in Takayasu's arteritis as initial presentation. Case summary All three cases were males and presented with complaints of abdominal pain and refractory hypertension. The diagnosis was made from the finding of thickened and calcified aortic wall, stenosis of visceral arteries, and age < 40 years at diagnosis. Case 1 was a 34 years male with aortic aneurysm extending from left subclavian artery to infrarenal aorta. He underwent endovascular repair of aneurysm by sandwich chimney technique in view of impending aneurysm rupture. Case 2, a 37 years male had aortic aneurysm from descending thoracic aorta (D4 vertebral body) to infrarenal aorta (L4 level). While being evaluated for repair, he had sudden death probably due to ruptured aneurysm. Case three, a 40 years male had aortic aneurysm extending from left subclavian artery to aortic bifurcation and stenosis of visceral arteries. He did not consent for repair and died one year later due to chronic kidney disease and related complications. Discussion Thoracoabdominal aortic aneurysm is a very rare manifestation in Takayasu's arteritis; more common in males. Endovascular repair is challenging but feasible. Long-term monitoring and repeat intervention may be needed due to young age of patients and disease progression.
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Affiliation(s)
- Anupam Jena
- Department of Cardiology, Kalinga Institute of Medical Sciences, Campus 5, KIIT University, Patia, Bhubaneswar, India
| | - Subasis Mishra
- Department of Cardiology, Kalinga Institute of Medical Sciences, Campus 5, KIIT University, Patia, Bhubaneswar, India
| | - Binayananda Padhee
- Department of Cardiology, Kalinga Institute of Medical Sciences, Campus 5, KIIT University, Patia, Bhubaneswar, India
| | - Surya Kant Jena
- Department of Cardiology, Kalinga Institute of Medical Sciences, Campus 5, KIIT University, Patia, Bhubaneswar, India
| | - Nelson Ghosh
- Department of Cardiology, Kalinga Institute of Medical Sciences, Campus 5, KIIT University, Patia, Bhubaneswar, India
| | - Prasanta Padhan
- Department of Immunology, Kalinga Institute of Medical Sciences, KIIT University, Patia, Bhubaneswar, India
| | - Nikunja Kishore Rout
- Department of Nephrology, Kalinga Institute of Medical Sciences, KIIT University, Patia, Bhubaneswar, India
| | - Panchanan Sahoo
- Department of Cardiology, Kalinga Institute of Medical Sciences, Campus 5, KIIT University, Patia, Bhubaneswar, India
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15
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Chellasamy RT, Krishnaswami M. Reinterventions after TEVAR. Indian J Thorac Cardiovasc Surg 2023; 39:325-332. [PMID: 38093920 PMCID: PMC10713966 DOI: 10.1007/s12055-023-01646-w] [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: 08/25/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 12/17/2023] Open
Abstract
Thoracic cardiovascular aortic repair is an alternative procedure to open surgery for degenerative thoracic aortic aneurysm and thoracic aortic dissection. The advancements in graft design and imaging techniques have expanded its utility. However, the long-term patency of thoracic endovascular aortic repair (TEVAR) graft is still a concern. This review delves into the literature on re-intervention following TEVAR, highlighting factors that influence the re-intervention rate.
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Affiliation(s)
| | - Murali Krishnaswami
- Department of Radiology, Institute of Cardiac and Aortic Disorders, SIMS Hospital, Chennai, 600026 India
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16
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Moulakakis KG, Tsimpoukis A, Katsanos K, Sintou E, Papadoulas S. Re-Rupture 2 Years after Endovascular Aortic Aneurysm Repair Rupture. Vasc Endovascular Surg 2023; 57:760-763. [PMID: 36960838 DOI: 10.1177/15385744231166797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
Re-rupture 2 years after endovascular aortic aneurysm repair (EVAR) rupture is an extremely rare event and limited data exist in the literature. We present an interesting case of a patient with an abdominal aortic rupture that had undergone 2 years before an endovascular repair for rupture after EVAR due to a type IA endoleak. The patient underwent a successful embolization of the type IA endoleak. Onyx was used to seal the gutter between the aortic wall and the endograft and the 1-month post-embolization CT showed complete sealing with no contrast in the sac. Two years after the rupture, he was presented again with clinical signs of hemodynamic shock and instability. An urgent CT Angiograph showed again rupture due to a type IA endoleak. The patient underwent an emergency open laparotomy. We analyze the re-rupture after EVAR while taking data from the literature into account.
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Affiliation(s)
| | | | | | - Eleni Sintou
- Department of Anesthesia, Patras University Hospital, Patras, Greece
| | - Spyros Papadoulas
- Vascular Surgery Department, Patras University Hospital, Patras, Greece
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17
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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Hüttl A, Nagy Z, Szentiványi A, Szeberin Z, Csobay-Novák C. [Secondary ruptures of an abdominal aortic aneurysm treated with a physician-modified fenestrated endograft, endoanchors and finally with open repair]. Orv Hetil 2023; 164:1426-1431. [PMID: 37695716 DOI: 10.1556/650.2023.32856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/12/2023] [Indexed: 09/13/2023]
Abstract
Secondary rupture is a late complication of endovascular aneurysm repair (EVAR). Open surgery is a technically feasible treatment option in most cases, however, late conversion carries a significant risk of morbidity and mortality, as it usually requires at least partial explantation of the in situ device, which is of major concern especially if suprarenal fixation is present. Endovascular treatment of these cases is usually challenging, especially since the custom-made devices that are often needed are not readily available but having a production time of several weeks. To overcome this limitation, physician-modified stent grafts are getting accepted to treat such urgent cases. We present the case of a patient receiving EVAR who later experienced two ruptures, treated first with a physician-modified endograft and adjunctive endoanchoring, later with open ligation of the lumbar arteries. Orv Hetil. 2023; 164(36): 1426-1431.
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Affiliation(s)
- Artúr Hüttl
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Intervenciós Radiológiai Tanszék Budapest, Határőr út 18., 1122 Magyarország
| | - Zsuzsa Nagy
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Érsebészeti és Endovaszkuláris Tanszék Budapest Magyarország
| | - András Szentiványi
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Intervenciós Radiológiai Tanszék Budapest, Határőr út 18., 1122 Magyarország
| | - Zoltán Szeberin
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Érsebészeti és Endovaszkuláris Tanszék Budapest Magyarország
- 3 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Semmelweis Aortacentrum Budapest Magyarország
| | - Csaba Csobay-Novák
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Intervenciós Radiológiai Tanszék Budapest, Határőr út 18., 1122 Magyarország
- 3 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Semmelweis Aortacentrum Budapest Magyarország
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19
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Zuccon G, D'Oria M, Gonçalves FB, Fernandez-Prendes C, Mani K, Caldeira D, Koelemay M, Bissacco D, Trimarchi S, Van Herzeele I, Wanhainen A. Incidence, Risk Factors, and Prognostic Impact of Type Ib Endoleak Following Endovascular Repair for Abdominal Aortic Aneurysm: Scoping Review. Eur J Vasc Endovasc Surg 2023; 66:352-361. [PMID: 37356703 DOI: 10.1016/j.ejvs.2023.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 05/23/2023] [Accepted: 06/17/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE The primary objectives of this scoping review were to assess the rate of and risk factors for type Ib endoleak and to evaluate the extent of the evidence base that links type Ib endoleak to short and long term outcomes in patients undergoing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). METHODS Potentially eligible studies were searched in the Cochrane Central Register of Controlled Trials, MEDLINE, Web of Science Core Collection, SciELO Citation Index, Russian Science Citation Index, and KCI-Korean Journal Database. A scoping review was performed according to PRISMA extension for Scoping Reviews. RESULTS A total of 27 articles (four prospective registries and 23 retrospective cohort studies) dealing with type Ib endoleak were included in the final analysis. The number of patients reported on was 7 197, with follow up ranging between 12 months and 93 months. The reported frequency of type Ib endoleak in patients treated with EVAR ranged from 0% to 8%, Patient and or procedure related factors associated with risk of type Ib endoleak were (1) common iliac artery (CIA) diameter ˃ 18 mm requiring use of flared stent graft limbs (FLs) ˃ 20 mm, (2) length of CIA landing zone ˂ 20 mm, (3) marked iliac tortuosity, and (4) large initial AAA diameter. Depending on the study, 50 - 100% of type Ib endoleaks were corrected by endovascular means, with a reported immediate technical success of 100% in the studies providing this information. CONCLUSION Type Ib endoleak after EVAR has been reported to occur in 0 - 8% of cases. Several anatomical features, including CIA diameter ˃ 18 mm or requiring the use of FLs ˃ 20 mm, length of CIA landing zone ˂ 20 mm, marked iliac tortuosity, and large initial AAA diameter, could increase the risk of type Ib endoleak and may require alternative therapeutic options and or more stringent follow up. Therefore, this updated scoping review provides a comprehensive summary of the frequency, risk factors, prognosis, and treatment of type Ib endoleaks, and has identified knowledge gaps in the literature to guide further studies.
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Affiliation(s)
- Gianmarco Zuccon
- Vascular Division, Cardiovascular Department, HPG23 Hospital, Bergamo, Italy. http://www.twitter.com/MarioDoria14
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy.
| | - Frederico Bastos Gonçalves
- NOVA Medical School - Faculdade de Ciências Médicas (NMS|FCM), Universidade Nova de Lisboa, Lisbon, Portugal
| | | | - Kevin Mani
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Daniel Caldeira
- Serviço de Cardiologia, Hospital Universitário de Santa Maria - CHULN, Portugal; Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), CAML, CEMBE, Faculdade de Medicina, Universidade de Lisboa, Portugal; Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Mark Koelemay
- Department of Surgery, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Daniele Bissacco
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Santi Trimarchi
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Anders Wanhainen
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Peri-operative and Surgical Sciences, Surgery, Umeå University, Umeå, Sweden
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Zuidema R, Geraedts ACM, van Veldhuizen WA, Mulay S, de Vries JPPM, Schuurmann RCL, Balm R. Diminishing Endograft Apposition during Follow-Up Is an Important Indicator of Late Type 1a Endoleak after Endovascular Aneurysm Repair. J Clin Med 2023; 12:3969. [PMID: 37373662 PMCID: PMC10299238 DOI: 10.3390/jcm12123969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/30/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Late type 1a endoleaks (T1aELs) after endovascular aneurysm repair (EVAR) are hazardous complications which should be avoided. This study investigated the evolution of the shortest apposition length (SAL) post-EVAR and hypothesised that a declining apposition during follow-up may be an indicator of T1aEL development. Patients with a late T1aEL were selected from a consecutive multicentre database. For each T1aEL patient, the preoperative computed tomography angiography (CTA), first postoperative CTA, and pre-endoleak CTA were analysed. T1aEL patients were matched 1:1 to uncomplicated controls, based on endograft type and follow-up duration. Anatomical characteristics and endograft dimensions, including the post-EVAR SAL, were measured. Included were 28 patients with a late T1aEL and 28 matched controls. The SAL decreased from 11.2 mm (5.6-20.6 mm) to 3.9 mm (0.0-11.4 mm) in the T1aEL group (p = 0.006), whereas an increase in SAL was seen in the control group from 21.3 mm (14.1-25.8 mm) to 25.4 mm (19.0-36.2 mm; p = 0.015). On the pre-endoleak CTA, 18 patients (64%) in the T1aEL group had a SAL < 10 mm, and one (4%) patient in the control group had a SAL < 10 mm on the matched CTAs. Moreover, three mechanisms of decreasing sealing zone were identified, which might be used to determine optimal imaging or reintervention strategies. Diminishing SAL < 10 mm is an indicator for T1aEL during follow-up, it is imperative to include apposition analysis during follow-up.
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Affiliation(s)
- Roy Zuidema
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (W.A.v.V.); (J.-P.P.M.d.V.); (R.C.L.S.)
| | - Anna C. M. Geraedts
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (A.C.M.G.); (S.M.); (R.B.)
| | - Willemina A. van Veldhuizen
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (W.A.v.V.); (J.-P.P.M.d.V.); (R.C.L.S.)
| | - Sana Mulay
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (A.C.M.G.); (S.M.); (R.B.)
| | - Jean-Paul P. M. de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (W.A.v.V.); (J.-P.P.M.d.V.); (R.C.L.S.)
| | - Richte C. L. Schuurmann
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (W.A.v.V.); (J.-P.P.M.d.V.); (R.C.L.S.)
| | - Ron Balm
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (A.C.M.G.); (S.M.); (R.B.)
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21
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Jones M, Faris P, Moore R. Mortality and risk factors for ruptured abdominal aortic Aneurysm after Repair Endovascular (rARE). J Vasc Surg Cases Innov Tech 2023. [DOI: 10.1016/j.jvscit.2023.101165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
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22
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Sen I, Kanzafarova I, Yonkus J, Mendes BC, Colglazier JJ, Shuja F, DeMartino RR, Kalra M, Rasmussen TE. Clinical presentation, operative management, and long-term outcomes of rupture after previous abdominal aortic aneurysm repair. J Vasc Surg 2023; 77:396-405.e7. [PMID: 36272507 DOI: 10.1016/j.jvs.2022.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/30/2022] [Accepted: 08/08/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate the presentation trends, intervention, and survival of patients who had been treated for late abdominal aortic aneurysm rupture (LAR) after open repair (OR) or endovascular aortic aneurysm repair (EVAR). METHODS We reviewed the clinical data from a single-center, retrospective database for patients treated for LAR from 2000 to 2020. The end points were the 30-day mortality, major postoperative complication, and survival. The outcomes between LAR managed with EVAR (group I) vs OR were compared (group II). RESULTS Of 390 patients with infrarenal aortic rupture, 40 (10%) had experienced aortic rupture after prior aortic repair and comprised the LAR cohort (34 men; age 78 ± 8 years). LAR had occurred before EVAR in 30 and before OR in 10 patients. LAR was more common in the second half of the study with 32 patients after 2010. LAR after prior OR was secondary to ruptured para-anastomotic pseudoaneurysms. After initial EVAR, LAR had occurred despite reintervention in 17 patients (42%). The time to LAR was shorter after prior EVAR than after OR (6 ± 4 vs 12 ± 4 years, respectively; P = .003). Treatment for LAR was EVAR for 25 patients (63%; group I) and OR for 15 (37%, group II). LAR after initial OR was managed with endovascular salvage for 8 of 10 patients. Endovascular management was more frequent in the latter half of the study period. In group I, fenestrated repair had been used for seven patients (28%). Salvage for the remaining cases was feasible with EVAR, aortic cuffs, or limb extensions. The incidence of free rupture, time to treatment, 30-day mortality (8% vs 13%; P = .3), complications (32% vs 60%; P = .1), and disposition were similar between the two groups. Those in group I had had less blood loss (660 vs 3000 mL; P < .001) and less need for dialysis (0% vs 33%; P < .001) than those in group II. The median follow-up was 21 months (interquartile range, 6-45 months). The overall 1-, 3-, and 5-year survival was 76%, 52%, and 41%, respectively, and was similar between groups (28 vs 22 months; P = .48). Late mortality was not related to the aorta. CONCLUSIONS LAR after abdominal aortic aneurysm repair has been encountered more frequently in clinical practice, likely driven by the frequency of EVAR. However, most LARs, including those after previous OR, can now be salvaged with endovascular techniques with lower morbidity and mortality.
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Affiliation(s)
- Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
| | - Irina Kanzafarova
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jennifer Yonkus
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Todd E Rasmussen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
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Elsayed N, Alhakim R, Al Nouri O, Baril D, Weaver F, Malas MB. Perioperative and long-term outcomes after open conversion of endovascular aneurysm repair versus primary open aortic repair. J Vasc Surg 2023; 77:89-96. [PMID: 35934217 DOI: 10.1016/j.jvs.2022.07.172] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/15/2022] [Accepted: 07/24/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The use of endovascular abdominal aortic aneurysm repair (EVAR) has superseded that of open aneurysm repair (OAR) as the procedure of choice for abdominal aortic aneurysm repair. However, significant rates of late reintervention and aneurysm rupture have been reported after EVAR, resulting in the need for conversion to OAR (C-OAR). To assess the relative effects of C-OAR on patients, we compared the outcomes of these patients to those of patients who had undergone P-OAR. METHODS The data from all patients who had undergone C-OAR and P-OAR in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database from 2003 to 2018 were queried. Multivariable logistic regression and Kaplan-Meier survival and Cox proportional hazard regression analyses were used to assess the perioperative long-term outcomes. RESULTS A total of 4763 patients were included (91.4%, P-OAR; 8.6%, C-OAR). C-OAR was associated with a significant increase in the odds of perioperative mortality (odds ratio, 1.7; 95% confidence interval [CI], 1.1-2.7; P = .027) and renal complications (odds ratio, 1.5; 95% CI, 1.1-2; P = .004) vs P-OAR. At 5 years, conversion was associated with a higher risk of mortality (hazard ratio [HR], 1.5; 95% CI, 1.3-1.9; P < .001), aneurysmal rupture (HR, 1.9; 95% CI, 1.2-3.1; P = .007), and reintervention (HR, 1.4; 95% CI, 1.05-1.97; P = .022) compared with P-OAR. These results also persisted at 10 years, with conversion associated with a higher risk of mortality (HR, 1.5; 95% CI, 1.2-1.8; P < .001), rupture (HR, 1.8; 95% CI, 1.1-2.8; P = .018), and reintervention (HR, 1.5; 95% CI, 1.1-2.1; P = .010). CONCLUSIONS The results from the present study have demonstrated that C-OAR is associated with a significantly higher risk of perioperative morbidity and mortality compared with P-OAR. We found a significant increase in mortality, aneurysm rupture, and reintervention at 5 and 10 years of follow-up.
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Affiliation(s)
- Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Rami Alhakim
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Omar Al Nouri
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Donald Baril
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Fred Weaver
- Division of Vascular and Endovascular Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA.
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24
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Alexander LF, Overfield CJ, Sella DM, Clingan MJ, Erben YM, Metcalfe AM, Robbin ML, Caserta MP. Contrast-enhanced US Evaluation of Endoleaks after Endovascular Stent Repair of Abdominal Aortic Aneurysm. Radiographics 2022; 42:1758-1775. [PMID: 36190857 DOI: 10.1148/rg.220046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Ruptured abdominal aortic aneurysm (AAA) carries high morbidity and mortality. Elective repair of AAA with endovascular stent-grafts requires lifetime imaging surveillance for potential complications, most commonly endoleaks. Because endoleaks result in antegrade or retrograde systemic arterialized flow into the excluded aneurysm sac, patients are at risk for recurrent aneurysm sac growth with the potential to rupture. Multiphasic CT has been the main imaging modality for surveillance and symptom evaluation, but contrast-enhanced US (CEUS) offers a useful alternative that avoids radiation and iodinated contrast material. CEUS is at least equivalent to CT for detecting endoleak and may be more sensitive. The authors provide a general protocol and technical considerations needed to perform CEUS of the abdominal aorta after endovascular stent repair. When there are no complications, the stent-graft lumen has homogeneous enhancement, and no contrast material is present in the aneurysm sac outside the stented lumen. In patients with an antegrade endoleak, contrast material is seen simultaneously in the aneurysm sac and stent-graft lumen, while delayed enhancement in the sac is due to retrograde leak. Recognition of artifacts and other potential pitfalls for CEUS studies is important for examination performance and interpretation. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Lauren F Alexander
- From the Departments of Radiology (L.F.A., C.J.O., D.M.S., M.J.C., A.M.M., M.P.C.) and Vascular Surgery (Y.M.E.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224; and Department of Radiology, University of Alabama Birmingham, Birmingham, Ala (M.L.R.)
| | - Cameron J Overfield
- From the Departments of Radiology (L.F.A., C.J.O., D.M.S., M.J.C., A.M.M., M.P.C.) and Vascular Surgery (Y.M.E.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224; and Department of Radiology, University of Alabama Birmingham, Birmingham, Ala (M.L.R.)
| | - David M Sella
- From the Departments of Radiology (L.F.A., C.J.O., D.M.S., M.J.C., A.M.M., M.P.C.) and Vascular Surgery (Y.M.E.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224; and Department of Radiology, University of Alabama Birmingham, Birmingham, Ala (M.L.R.)
| | - M Jennings Clingan
- From the Departments of Radiology (L.F.A., C.J.O., D.M.S., M.J.C., A.M.M., M.P.C.) and Vascular Surgery (Y.M.E.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224; and Department of Radiology, University of Alabama Birmingham, Birmingham, Ala (M.L.R.)
| | - Young M Erben
- From the Departments of Radiology (L.F.A., C.J.O., D.M.S., M.J.C., A.M.M., M.P.C.) and Vascular Surgery (Y.M.E.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224; and Department of Radiology, University of Alabama Birmingham, Birmingham, Ala (M.L.R.)
| | - Allie M Metcalfe
- From the Departments of Radiology (L.F.A., C.J.O., D.M.S., M.J.C., A.M.M., M.P.C.) and Vascular Surgery (Y.M.E.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224; and Department of Radiology, University of Alabama Birmingham, Birmingham, Ala (M.L.R.)
| | - Michelle L Robbin
- From the Departments of Radiology (L.F.A., C.J.O., D.M.S., M.J.C., A.M.M., M.P.C.) and Vascular Surgery (Y.M.E.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224; and Department of Radiology, University of Alabama Birmingham, Birmingham, Ala (M.L.R.)
| | - Melanie P Caserta
- From the Departments of Radiology (L.F.A., C.J.O., D.M.S., M.J.C., A.M.M., M.P.C.) and Vascular Surgery (Y.M.E.), Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224; and Department of Radiology, University of Alabama Birmingham, Birmingham, Ala (M.L.R.)
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25
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Andersson M, Sandström C, Stackelberg O, Lundqvist R, Nordanstig J, Jonsson M, Roy J, Andersson M, Hultgren R, Roos H. Editor's Choice - Structured Computed Tomography Analysis can Identify the Majority of Patients at Risk of Post-Endovascular Aortic Repair Rupture. Eur J Vasc Endovasc Surg 2022; 64:166-174. [PMID: 35561947 DOI: 10.1016/j.ejvs.2022.04.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 04/13/2022] [Accepted: 04/30/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The main objective was to report mechanisms and precursors for post-endovascular aneurysm repair (EVAR) rupture. The second was to apply a structured protocol to explore whether these factors were identifiable on follow up computed tomography (CT) prior to rupture. The third objective was to study the incidence, treatment, and outcome of post-EVAR rupture. METHODS This was a multicentre, retrospective study of patients treated with standard EVAR at five Swedish hospitals from 2008 to 2018. Patients were identified from the Swedvasc registry. Medical records were reviewed up to 2020. Index EVAR and follow up data were recorded. The primary endpoint was post-EVAR rupture. CT at follow up and at post-EVAR rupture were studied, using a structured protocol, to determine rupture mechanisms and identifiable precursors. RESULTS In 1 805 patients treated by EVAR, 45 post-EVAR ruptures occurred in 43 patients. The cumulative incidence was 2.5% over a mean follow up of 5.2 years. The incidence rate was 4.5/1 000 person years. Median time to post-EVAR rupture was 4.1 years. A further six cases of post-EVAR rupture in five patients found outside the main cohort were included in the analysis of rupture mechanisms only. The rupture mechanism was type IA in 20 of 51 cases (39%), IB in 20 of 51 (39%) and IIIA/B in 11 of 51 (22%). One of these had type IA + IB combined. One patient had an aortoduodenal fistula without another mechanism being identified. Precursors had been noted on CT follow up prior to post-EVAR rupture in 16 of 51 (31%). Retrospectively, using the structured protocol, precursors could be identified in 43 of 51 (84%). In 17 of 27 (63%) cases missed on follow up but retrospectively identifiable, the mechanisms were type IB/III. Overall, the 30 day mortality rate after post-EVAR rupture was 47% (n = 24/51) and the post-operative mortality rate was 21% (n = 7/33). CONCLUSIONS Most precursors of post-EVAR rupture are underdiagnosed but identifiable before rupture using a structured follow up CT protocol. Precursors of type IB and III failures caused the majority of post-EVAR ruptures.
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Affiliation(s)
- Mattias Andersson
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sunderbyn Hospital, Sunderbyn, Sweden
| | - Charlotte Sandström
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Otto Stackelberg
- Section of Vascular Surgery, Department of Clinical Science and Education, Karolinska Institutet at Södersjukhuset, Stockholm, Sweden; Institute of Environmental Medicine, Unit of Cardiovascular and Nutritional Epidemiology, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Robert Lundqvist
- Department of Public Health and Clinical Medicine, Umeå University, Norrbotten County Council, Umeå, Sweden
| | - Joakim Nordanstig
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Jonsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Manne Andersson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Surgery, Ryhov Hospital, Jönköping, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Håkan Roos
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Ryhov Hospital, Jönköping, Sweden.
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Hauck SR, Schernthaner R, Dachs TM, Kern M, Funovics M. Endovaskuläre Aortenreparatur bei Endoleaks. DIE RADIOLOGIE 2022; 62:592-600. [PMID: 35736998 PMCID: PMC9242926 DOI: 10.1007/s00117-022-01033-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 11/25/2022]
Abstract
Sämtliche Patienten nach endovaskulärer Versorgung eines Aortenaneurysmas bedürfen einer regelmäßigen Nachkontrolle, zumeist in jährlichem Abstand. Der kontrastmittelverstärkte Ultraschall und die Computertomographie-Angiographie (CTA) sind die wichtigsten diagnostischen Modalitäten für die Erkennung von Endoleaks. Die (CTA) erlaubt eine bessere Unterscheidung der verschiedenen Endoleak-Typen. Sogenannte Hochdruck-Endoleaks (Typ I und Typ III) stellen, wenn sich nicht kurzzeitig ein Spontanverschluss zeigt, eine absolute Indikation zur Nachbehandlung dar. Typ-II-Endoleaks weisen in der Mehrzahl einen benignen Verlauf auf. Wenn kein Wachstum des Aneurysmasacks erfolgt, kann eine Nachkontrolle im gewohnten Intervall durchgeführt werden. Typ-II-Endoleaks mit assoziiertem Wachstum des Aneurysmasacks können durch Embolisation der verantwortlichen Gefäße behandelt werden. Ob eine Behandlung immer durchgeführt werden muss, ist umstritten. Eine Behandlungsindikation von einem Typ-II-Endoleak mit wachsendem Aneurysmasack ist jedoch gegeben, wenn durch eine Verkürzung des Aneurysmahalses ein sekundäres Typ-I-Endoleak droht. Typ-I-Endoleaks stellen die Hauptlimitation der Stentgraft-Therapie dar. Die beste Prävention eines Typ-I-Endoleaks ist die Bereitstellung einer adäquaten proximalen Landezone. Dies kann durchaus bedeuten, dass fenestrierte Stentgrafts verwendet werden müssen. Die Verwendung von Schrauben oder anderen Fixationsinstrumenten zur sicheren Behandlung auch kurzer Hälse ist derzeit noch in der Studienphase.
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Affiliation(s)
- Sven Rudolf Hauck
- Abteilung für Kardiovaskuläre und Interventionelle Radiologie, Universitätsklinik für Radiologie und Nuklearmedizin, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Rüdiger Schernthaner
- Zentrales Radiologie Institut - Diagnostische und Interventionelle Radiologie, Klinik Landstraße, Wien, Österreich
| | - Theresa-Marie Dachs
- Abteilung für Kardiovaskuläre und Interventionelle Radiologie, Universitätsklinik für Radiologie und Nuklearmedizin, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Maximilian Kern
- Institut für Radiologie, Klinik Floridsdorf, Wien, Österreich
| | - Martin Funovics
- Abteilung für Kardiovaskuläre und Interventionelle Radiologie, Universitätsklinik für Radiologie und Nuklearmedizin, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
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Yei K, Mathlouthi A, Naazie I, Elsayed N, Clary B, Malas M. Long-term Outcomes Associated With Open vs Endovascular Abdominal Aortic Aneurysm Repair in a Medicare-Matched Database. JAMA Netw Open 2022; 5:e2212081. [PMID: 35560049 PMCID: PMC9107027 DOI: 10.1001/jamanetworkopen.2022.12081] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
IMPORTANCE Endovascular aneurysm repair is associated with a significant reduction in perioperative mortality and morbidity compared with open aneurysm repair in the treatment of abdominal aortic aneurysm. However, this benefit decreases over time owing to increased reinterventions and late aneurysm rupture after endovascular repair. OBJECTIVE To compare long-term outcomes of endovascular vs open repair of abdominal aortic aneurysm. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study used deidentified data with 6-year follow-up from the Medicare-matched Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database. Patients undergoing first-time elective endovascular or open abdominal aortic aneurysm repair from 2003 to 2018 were propensity score matched. Patients with ruptured abdominal aortic aneurysm, concomitant procedures, or prior history of abdominal aortic aneurysm repair, were excluded. Data were analyzed from January 1, 2003, to December 31, 2018. EXPOSURES First-time elective endovascular or open repair for abdominal aortic aneurysm. MAIN OUTCOMES AND MEASURES The primary long-term outcome of interest was 6-year all-cause mortality, rupture, and reintervention. Secondary outcomes included 30-day mortality and perioperative complications. RESULTS Among a total of 32 760 patients (median [IQR] age, 75 [70-80] years; 25 706 [78.5%] men) who underwent surgical abdominal aortic aneurysm repair, 28 281 patients underwent endovascular repair and 4479 patients underwent open repair. After propensity score matching, there were 2852 patients in each group. Open repair was associated with significantly lower 6-year mortality compared with endovascular repair (548 deaths [35.6%] vs 608 deaths [41.2%]; hazard ratio [HR], 0.83; 95% CI, 0.74-0.94; P = .002), with increases in mortality starting from 1 to 2 years (84 deaths [4.3%] vs 126 deaths [6.7%]; HR, 0.63; 95% CI, 0.48-0.83; P = .001) and 2 to 6 years (211 deaths [25.8%] vs 241 deaths [30.6%]; HR, 0.73; 95% CI, 0.61-0.88; P = .001). Open repair, compared with endovascular repair, also was associated with significantly lower rates of 6-year rupture (117 participants [5.8%] vs 149 participants [8.3%]; HR, 0.76; 95% CI, 0.60-0.97; P < .001) and reintervention (190 participants [11.6%] vs 267 participants [16.0%]; HR, 0.67; 95% CI, 0.55-0.80; P < .001). Open repair was associated with significantly higher odds of 30-day mortality (OR, 3.56; 95% CI, 2.41-5.26; P < .001) and complications. CONCLUSIONS AND RELEVANCE These findings suggest that overall mortality after elective abdominal aortic aneurysm repair was higher with endovascular repair than open repair despite reduced 30-day mortality and perioperative morbidity after endovascular repair. Endovascular repair additionally was associated with significantly higher rates of long-term rupture and reintervention. These findings emphasize the importance of careful patient selection and long-term follow-up surveillance for patients who undergo endovascular repair.
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Affiliation(s)
- Kevin Yei
- University of California, San Diego, La Jolla
| | | | | | | | - Bryan Clary
- University of California, San Diego, La Jolla
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Boer GJ, Schröder LBW, Disli MC, Kuijper TM, van de Luijtgaarden KM, Fioole B. A stable aneurysm sac after endovascular aneurysm repair as a predictor for mortality, an in-depth analysis. J Vasc Surg 2022; 76:445-453. [PMID: 35149164 DOI: 10.1016/j.jvs.2022.01.125] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/21/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to compare the long-term survival in patients with a stable aneurysmal sac and those with aneurysmal sac regression after endovascular aneurysm repair (EVAR) and to identify independent risk factors for aneurysmal sac regression and mortality after EVAR. METHODS We reviewed all patients who underwent EVAR between 2005 and 2018 with a computed tomography angiography available at 1-year follow-up. Aneurysm sac regression was defined as a diameter decrease of more than 10%. We used a multivariable regression to identify independent risk factors for sac regression. Kaplan-Meier analysis and Cox regression were done to test differences in 5-year mortality between a stable sac and sac regression. RESULTS The inclusion criteria were met by 325 patients, 185 in the sac regression group and 140 in the stable sac group. Multivariable logistic regression analysis showed that treatment for a ruptured aneurysm was an independent risk factor for aneurysmal sac regression (hazard ratio [HR], 0.26; 95% confidence interval [CI], 0.07-0.96). Age (HR, 1.05; 95% CI, 1.01-1.09), ischemic heart disease (HR, 1.94; 95% CI, 1.13-3.31), neck thrombus (HR, 2.72; 95% CI, 1.07-6.95), and a type II endoleak (HR, 19.21; 95% CI, 7.32-50.40) were independent risk factors for a stable aneurysm sac diameter. Multivariable Cox regression showed a significantly increased risk of mortality for patients with a stable aneurysm sac after EVAR (odds ratio, 2.25; 95% CI, 1.36-3.72). There was no significant difference in cause of death between the two groups. CONCLUSION A stable aneurysm sac after EVAR is associated with increased mortality. Age, ischemic heart disease, neck thrombus, and a type II endoleak are independent risk factors for a stable sac. However, a well-founded explanation for this finding is still lacking. Future research should be focussed on aggressive treatment of type II endoleaks and inflammatory processes as potential pathophysiological mechanisms.
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Affiliation(s)
- Gert Jan Boer
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands.
| | | | - Maksud C Disli
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Tjallingius M Kuijper
- Clinical epidemiologist and statistician, Maasstad Academy, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
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Open surgical conversion and management of patients with ruptured abdominal aortic aneurysm after previous endovascular aneurysm repair. SRP ARK CELOK LEK 2022. [DOI: 10.2298/sarh211229067m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction/Objective. The objective was to present the results and technical considerations from high-volume center when performing late open surgical conversion (LOSC) after endovascular aneurysm repair (EVAR) in ruptured abdominal aortic aneurysm (RAAA) patients. Methods. This was a single center retrospective study. LOSC was performed whenever eventual endovascular reintervention failed, was not feasible due to hostile anatomy and unavailability of specific endograft materials, or when patient was hemodynamically unstable necessitating emergent surgery. Results. All previously implanted EVARs had bimodular configuration with suprarenal fixation. Total endograft explantation was performed in 40% of patients. Hospital mortality was 20%. Both patients who died had total endograft explantation with supraceliac clamp lasting more than 30 minutes. 30-day mortality was 30%, with one more patient who died from pulmonary embolism after hospital discharge and two hospital deaths were due to myocardial infarction. Conclusion. LOSC due to RAAA after previous EVAR carries greater mortality for the patient, suggesting multifactorial impacts on the outcome. The appropriate choice of surgical method and technical success are of ultimate importance, with total graft explantation having negative impact on patient?s survival.
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Burke CT, Yu H. How I Do It: Computed Tomography-Guided Modified Translumbar Embolization of Type 2 Endoleak. Semin Intervent Radiol 2021; 38:576-580. [PMID: 34853504 DOI: 10.1055/s-0041-1736656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Charles T Burke
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Hyeon Yu
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
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Long-term Outcomes after FEVAR for Juxtarenal Aortic Aneurysm. J Vasc Surg 2021; 75:1164-1170. [PMID: 34838610 DOI: 10.1016/j.jvs.2021.11.050] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 11/07/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Fenestrated endovascular aortic repair (FEVAR) for juxtarenal aortic aneurysm (jAAA) disease is safe and effective with good short- and mid-term outcomes. Durability issues focus mainly on proximal and distal seal as well as target vessel (TV) instability, and long-term data is scarce. In previous publications we have reported short-term outcomes after FEVAR while comparing early- and late-experience patient groups, as well as long-term results for the early cohort. In this series we provide long-term outcome in the late experience cohort treated with FEVAR in Vascular Center Malmö. METHODS Consecutive patients treated in Vascular Center Malmö with FEVAR for jAAA between 2007 and 2011 were included. Data was collected retrospectively from medical- and imaging records. Follow up consisted of a clinical examination 1 month post-operatively, and computed tomography angiography combined with plain abdominal X-ray at 1 and 12 months, and annually thereafter. Primary endpoints were TV instability, reinterventions and survival. Changes in aneurysm diameter and renal function as well as endoleaks were also analyzed. RESULTS 94 patients were treated. Median follow-up time was 89 (range 0-152) months. 280 fenestrations or scallops were employed of which 205 were stented. Technical success was 89.4%. Primary TV patency was 94% ± 1 % at 1year, 90% ± 2% at 3 years and 89% ± 2% at 5 years. 37 (39.4%) patients needed a total of 70 reinterventions and mean time to first reintervention was 21 ± 3.97 months. 5 (5.3%) patients died of aneurysm related causes and overall survival was 95.7% ± 2.1% at 1 year, 87.1% ± 3.5% at 3 years and 71.0 ± 4.7% at 5 years. A stable or decreasing aortic diameter after treatment was seen in 91% of cases. Mean glomerular filtration rate (GFR) fell from 59.2 ± 14.9 ml/min/1.73m2 pre-operatively to 50.0 ± 18.6 ml/min/1.73 m2 at end of follow-up. CONCLUSION Long-term results after treatment of jAAA with FEVAR remain good and the treatment is safe and effective. Although the need for reintervention remains high, long-term renal function and survival support the use of FEVAR as a valid treatment option for jAAA disease.
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O'Donnell TF, McElroy IE, Mohebali J, Boitano LT, Lamuraglia GM, Kwolek CJ, Conrad MF. Late Type 1A Endoleaks: Associated Factors, Prognosis and Management Strategies. Ann Vasc Surg 2021; 80:273-282. [PMID: 34752856 DOI: 10.1016/j.avsg.2021.08.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/13/2021] [Accepted: 08/19/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Unlike periprocedural Type 1A endoleaks, late appearing proximal endoleaks have been poorly described. METHODS We studied all elective EVAR from 2010 -2018 in a single institution. Late endoleaks were defined as those appearing after 1 year. We used Cox regression to study factors associated with late Type 1A endoleaks and survival. RESULTS Of 477 EVAR during the study period, 411 (86%) had follow-up imaging, revealing 24 Type 1A endoleaks; 4 early and 20 late. Freedom from Type 1A endoleaks was 99%, 92-81% at 1, 5 and 8 years with a median time to occurrence of 2.5 years (.01-8.2 years). On completion angiogram, only 10% of patients with a late Type 1A had a proximal endoleak, and 60% had no endoleak. Only 21% of late Type 1As were diagnosed on routine 1-year CT angiogram, but 79% had stable or expanding sacs. Two thirds (65%) of the patients eventually diagnosed with late Type 1A endoleaks had previously been treated for other endoleaks, mostly Type 2 (10/13). Age (HR 1.07/year [1.02-1.12], P = 0.01), neck diameter >28mm (HR 3.5 [1.2-10.3], P = 0.02), neck length <20mm (HR 3.0 [1.1-8.6], P = 0.04), and neck angle>60 degrees (HR 3.4 [1.5-7.9], P = 0.004) were associated with higher rates of Type 1A endoleak, but not female sex, endograft, or the use of suprarenal fixation. 2 patients had proximal degeneration and 5 experienced graft migration. There were 2 ruptures (10%), and 13 patients underwent repair with 5 open conversions. Median survival after late Type 1A repair was 6.6 years (0-8.4 years). CONCLUSION Late appearing Type 1A endoleaks have a high rate of rupture and present significant diagnostic and management challenges. Careful surveillance is needed in patients with hostile neck anatomy and those who undergo intervention for other endoleaks. Adverse neck anatomy may be better suited for open repair or fenestrated/branched devices rather than conventional EVAR.
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Affiliation(s)
- Thomas Fx O'Donnell
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Imani E McElroy
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Glenn M Lamuraglia
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Christopher J Kwolek
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
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Tan N, Shi Y, Xu D, Wang J. Unusual cause of gastrointestinal bleeding in an 84-year-old woman: a miraculous survival from an aortoduodenal fistula repair. BMJ Case Rep 2021; 14:e244318. [PMID: 34518182 PMCID: PMC8438823 DOI: 10.1136/bcr-2021-244318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 11/04/2022] Open
Abstract
An 84-year-old woman presented acutely with dizziness, fatigue and a total of 800 mL of fresh per rectum (PR) bleeding. The significant history of abdominal aortic aneurysm repair 5 years ago included multiple episodes of endovascular leak around the stent associated with abscess of left psoas major, left abdominal wall abscess with sinus formation, appendicitis with abscess formation, and acute pancreatic and chronic cholecystitis with multiple gallstones in the 7 months prior to this presentation. During the preceding 7 months, the patient was stabilised with an intravenous proton pump inhibitor, blood transfusions and Intensive Care Unit (ICU) management for the assumed diagnosis of stress ulcers over multiple hospital admissions. Imaging with CT scan of the abdomen made the more accurate diagnosis of acute gastrointestinal haemorrhage caused by a fistula between the distal duodenum and aorta, which was later surgically confirmed. Removal of infected stents and axillobifemoral bypass were performed with a successful recovery.
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Affiliation(s)
- Nicole Tan
- Curtin Medical School, Curtin University Bentley Campus, Perth, Bentley, Australia
| | - Yi Shi
- Vascular Surgery, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Dan Xu
- Curtin Medical School, Curtin University Bentley Campus, Perth, Bentley, Australia
- Curtin School of Population Health, Curtin University Bentley Campus, Perth, Bentley, Australia
- Medical Education and General Practice, Sun Yan-sen University of Medical Sciences, Guangzhou, China
| | - Jinsong Wang
- Vascular Surgery, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
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van Schaik TG, Meekel JP, Hoksbergen AWJ, de Vries R, Blankensteijn JD, Yeung KK. Systematic review of embolization of type I endoleaks using liquid embolic agents. J Vasc Surg 2021; 74:1024-1032. [PMID: 33940072 DOI: 10.1016/j.jvs.2021.03.061] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 03/29/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The long-term success of endovascular aneurysm repair (EVAR) is limited by complications, most importantly endoleaks. In case of (persistent) type I endoleak (T1EL), secondary intervention is indicated to prevent secondary aneurysm rupture. Different treatment options are suggested for T1ELs, such as endo anchors, (fenestrated) cuffs, embolization, or open conversion. Currently, the treatment of T1EL with liquid embolic agents is available; however, results are not yet addressed. This review presents the safety and efficacy of embolization with liquid embolic agents for treatment of T1ELs after EVAR. METHODS A systematic literature search was performed for all studies reporting the use of liquid embolic agents as monotherapy for treatment of T1ELs after EVAR. Patient numbers, technical success (successful delivery of liquid embolics in the T1EL) and clinical success (absence of aneurysm related death, endoleak recurrence or additional interventions during follow-up) were examined. RESULTS Of 1604 articles, 10 studies met the selection criteria, including 194 patients treated with liquid embolics; 73.2% of the patients were male with a median age of 71 years. The overall technical success was 97.9%. Clinical success was 87.6%. Because the median follow-up was only 13.0 months (range, 1-89 months), data on long-term success are almost absent. Four cases (2.1%) of secondary aneurysm rupture after embolization owing to endoleak recurrence were reported. All ruptures occurred in aneurysms exceeding initial treatment diameter of 70 mm. CONCLUSIONS Initial technical success after liquid embolization for T1EL is high, although long-term clinical success rates are lacking. Within this review, the risk of secondary rupture is comparable with untreated T1EL at 2% with a median follow-up of 13 months, regardless of the initial success of embolization. In general, no decrease in secondary aneurysm rupture after embolization of T1EL after EVAR is demonstrated, although the results of late embolization are debated.
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Affiliation(s)
- Theodorus G van Schaik
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands; Department of Surgery, Zaans Medisch Centrum, Zaandam The Netherlands
| | - Jorn P Meekel
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands; Department of Surgery, Zaans Medisch Centrum, Zaandam The Netherlands
| | - Arjan W J Hoksbergen
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands
| | - Ralph de Vries
- Clinical Library, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Jan D Blankensteijn
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands
| | - Kak K Yeung
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands.
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Smith AH, Farivar BS. A Novel Solution to Concomitant Type Ia/Type IIIa Endoleak Using the Cook Zenith Fenestrated Device and Endologix AFX ®2. Vasc Endovascular Surg 2021; 55:777-780. [PMID: 33866876 DOI: 10.1177/15385744211006611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Failing EVAR is typically treated with open explant or conversion to fenestrated endovascular repair. Novel solutions for EVAR salvage may be required in patients unable to tolerate explant or travel to centers with custom-fenestrated capabilities. However, strategies utilizing commercially available devices are often limited by anatomic constraints such as short renal artery to endograft bifurcation length. We present a case of progressive sac expansion due to late, concomitant type Ia and type IIIa endoleaks. The patient was successfully treated by proximal extension into the visceral segment using a Cook Zenith Fenestrated device and graft relining using the Endologix AFX®2.
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Affiliation(s)
- Andrew H Smith
- Department of Vascular Surgery, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Behzad S Farivar
- Division of Vascular and Endovascular Surgery, University of Virginia Heart and Vascular Center, Charlottesville, VA, USA
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Andersson M, Talvitie M, Benson L, Roy J, Roos H, Hultgren R. A population-based study of post-endovascular aortic repair rupture during 15 years. J Vasc Surg 2021; 74:701-710.e3. [PMID: 33617983 DOI: 10.1016/j.jvs.2021.01.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 01/21/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The devastating event of a ruptured abdominal aortic aneurysm (rAAA) in patients who have survived a previous AAA repair, either elective or urgent, is a feared and quite uncommon event. It has been suggested to partly explain the loss of the early survival benefit for endovascular aortic repair (EVAR) vs open surgical repair (OSR). The main objective of this study was to report the national incidence rate, risk factors and outcome of post-EVAR ruptures. Secondarily, the national incidence rate of ruptures after OSR (post-OSR ruptures) was investigated. METHODS We conducted a nationwide, population-based, retrospective cohort study using the inpatient and outpatient entries for all patients >40 years of age, receiving their first (index) surgical procedure for AAA, from 2001 to 2015. Only patients surviving their index procedure were included. The primary outcome was rAAA, registered after discharge from the index procedure (EVAR or OSR), identified in the Swedish National Patient Registry and the Cause of Death Registry. RESULTS In total, 14,859 patients survived their primary (index) AAA procedure. There were 6470 EVAR procedures, 5893 for intact AAA (iAAA) and 577 for rAAA. Of the 6470 EVAR patients, 86 cases of post-EVAR rupture were identified, corresponding with a cumulative incidence of 1.3% over a mean follow-up time of 3.9 years. The incidence rate was 3.4 (95% confidence interval [CI], 2.7-4.2)/1000 person-years. The independent risk factors identified for post-EVAR rupture were rAAA at index surgery HR 2.4 (95% CI, 1.4-4.1, p 0.002) and age (hazard ratio, 1.1; 95% CI, 1.0-1.1; P < .001). Freedom from post-EVAR rupture was 99%, 98%, and 96% at 3, 5, and 10 years, respectively. Total and postoperative mortality after post-EVAR rupture were 42% and 17% (30 days), 45% and 22% (90 days), and 53% and 33% (1 year). The incidence rate of post-OSR rupture was 0.9/1000 person-years (95% CI, 0.7-1.2). CONCLUSIONS Post-EVAR rupture is a rare complication that can occur at any time after the index EVAR procedure. This finding may have implications for the discussion of limited follow-up programs and for the choice of procedure in patients with an AAA with a long life expectancy. An rAAA as the indication for the index surgery and age were identified as risk factors for post-EVAR rupture. The mortality associated with post-EVAR rupture is high, but lower than that of primary rAAA. The much lower risk of post-OSR rupture was confirmed, but must not be neglected as a possible late complication.
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Affiliation(s)
- Mattias Andersson
- Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sunderbyn Hospital, Sunderbyn, Sweden.
| | - Mareia Talvitie
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Lina Benson
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Håkan Roos
- Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Ryhov Hospital, Jönköping, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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Doumenc B, Mesnard T, Patterson BO, Azzaoui R, De Préville A, Haulon S, Sobocinski J. Management of Type IA Endoleak After EVAR by Explantation or Custom Made Fenestrated Endovascular Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2021; 61:571-578. [PMID: 33414067 DOI: 10.1016/j.ejvs.2020.10.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 06/08/2020] [Accepted: 10/26/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Proximal type 1 endoleak after endovascular abdominal aortic aneurysmal repair (EVAR) remains challenging to solve with no existing consensus. This work aims to compare two different surgical strategies to remedy type IA endoleak: endograft explantation (EXP) and aortic reconstruction or relining by custom made fenestrated EVAR (F-EVAR). METHODS A retrospective single centre analysis between 2009 and 2018 was conducted including patients treated for type IA endoleak after EVAR with either EXP or F-EVAR. The choice of surgical technique was based on morphological factors (F-EVAR eligibility), sac growth rate, emergency presentation and/or patient symptoms. Technical success, morbidity, secondary interventions, 30 day mortality, and long term survival according to Kaplan-Meier were determined for each group and compared. RESULTS Fifty-nine patients (91% male, mean age 79 years) underwent either EXP (n = 26) or F-EVAR (n = 33) during the study period. The two groups were equivalent in terms of comorbidity and age at the time of procedure. The median time from initial EVAR was 60.4 months (34-85 months), with no difference between groups. The maximum aneurysm diameter was greater in the EXP group compared with the F-EVAR group, 86 mm (65-100) and 70 mm (60-80), respectively (p = .008). Thirty day secondary intervention (EXP: 11.5% vs. F-EVAR: 9.1%) and mortality (EXP: 3.8% vs. F-EVAR: 3.3%) rates did not differ between groups, while major adverse events at 30 days, defined by the current SVS guidelines, were lower in the F-EVAR group (2.4% vs. 13.6%; p = .016). One year survival rates were similar between the groups (EXP: 84.0% vs. F-EVAR: 86.6%). CONCLUSION Open explantation and endovascular management with a fenestrated device for type IA endoleak after EVAR can be achieved in high volume centres with satisfactory results. F-EVAR is associated with decreased early morbidity. Open explantation is a relevant option because of acceptable outcomes and the limited applicability of F-EVAR.
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Affiliation(s)
- Benoit Doumenc
- Service de chirurgie vasculaire, Centre de l'Aorte, CHU, Lille, France
| | - Thomas Mesnard
- Service de chirurgie vasculaire, Centre de l'Aorte, CHU, Lille, France; University of Lille, U1008 - Controlled Drug Delivery Systems and Biomaterials, Lille, France
| | | | - Richard Azzaoui
- Service de chirurgie vasculaire, Centre de l'Aorte, CHU, Lille, France
| | | | - Stephan Haulon
- Service de chirurgie vasculaire, Centre de l'Aorte, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Jonathan Sobocinski
- Service de chirurgie vasculaire, Centre de l'Aorte, CHU, Lille, France; University of Lille, U1008 - Controlled Drug Delivery Systems and Biomaterials, Lille, France.
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Bellamkonda K, Ochoa Chaar CI. Open repair of type III endoleak with preservation of the endograft for a ruptured abdominal aortic aneurysm after endovascular aneurysm repair. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 7:117-119. [PMID: 33718680 PMCID: PMC7921175 DOI: 10.1016/j.jvscit.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/10/2020] [Indexed: 10/28/2022]
Abstract
Abdominal aortic aneurysm rupture after endovascular aneurysm repair (EVAR) is rare, but remains a significant limitation of endovascular technology. Preservation of the endograft during open conversion of a post-EVAR rupture has been shown to be associated with improved perioperative outcomes. An interposition Dacron graft with felt pledgets is a novel bail-out option for the open reconstruction of a type III endoleak with total endograft preservation. This technique is useful in high-risk patients presenting with ruptured abdominal aortic aneurysm after EVAR and no clear source of endoleak.
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Affiliation(s)
- Kirthi Bellamkonda
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, New Haven, Conn
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De Santis F, Notari MP, Chiappa R. Early periaortic hematoma development after EVAR in the presence of severely calcified and modestly conical-shaped aortic neck: A potential trigger for sudden aneurysm progression toward rupture. Vascular 2020; 29:667-671. [PMID: 33308108 DOI: 10.1177/1708538120978030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this report is to present a singular case of early post-endovascular aneurysm repair abdominal aortic aneurysm rupture and discuss the possible etiopathogenic mechanism promoting the sudden aneurysm progression toward rupture.Methods/Results: An 84-year-old man was submitted to endovascular aneurysm repair via second-generation endograft (Cordis-Incraft Stent-graft) during which, the left occluded common iliac artery was recanalized via balloon-expandable covered-stent-graft (Atrium-Advanta-V12). The aneurysm presented a severely calcified and modestly conical-shaped aortic-neck. The post-operative course was complicated by a broncho pneumonic infiltrate and a CT scan performed two weeks postoperatively accidentally revealed a relatively small hematoma surrounding the aortic wall. No active bleeding, endoleak, or aneurysm increase in diameter was documented. Nevertheless, the patient remained closely monitored. Three days later, he suffered from abdominal aortic aneurysm rupture. A CT scan revealed an arterial wall tear at the neck level. Intra-operatively the reanalyzed common iliac artery was intact and a good endograft-sealing was confirmed. Following this event, small lumbar arteries suture saccotomy was performed. The patient eventually died of multiorgan failure one month later. CONCLUSIONS The apparently "self-limiting" post-endovascular aneurysm repair CT-scan finding of periaortic hematoma may have represented a potential trigger for abdominal aortic aneurysm rupture. The possibility of developing undetected aortic lesions during endovascular aneurysm repair, specifically in the presence of potentially "at risk" anatomical conditions, should always be considered.
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Affiliation(s)
| | | | - Roberto Chiappa
- Department of Vascular Surgery, Sandro Pertini Hospital, Rome, Italy
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Quaglino S, Mortola L, Ferrero E, Ferri M, Cirillo S, Lario CV, Negro G, Ricotti A, Gaggiano A. Long-term failure after endovascular aneurysm sealing in a real-life, single-center experience with the Nellix endograft. J Vasc Surg 2020; 73:1958-1965.e1. [PMID: 33278539 DOI: 10.1016/j.jvs.2020.11.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Endovascular aneurysm sealing (EVAS) is an innovative alternative to conventional endovascular aneurysm repair (EVAR). EVAS relies on sac anchoring without proximal fixation to achieve sealing and should have allowed for the treatment of a broader range of anatomic features compared with standard EVAR. Despite the encouraging early reports, the mid- and long-term follow-up data have shown increased rates of failure. To address the issue, the manufacturer introduced revised instructions for use (IFU) in 2016. The present study reports the outcomes of this system after a median follow-up of 45 months. METHODS Data for all patients electively treated with EVAS at our institution were retrospectively collected. The patients were retrospectively reclassified according to the 2016 revised IFU of the device. All patients in the present series had undergone EVAS for the treatment of infrarenal abdominal aortic aneurysms (AAAs). The primary end point was therapeutic failure: graft migration >5 mm, sac expansion >5 mm, type IA endoleak (Is2 and Is3 using the Van den Ham classification), type Ib endoleak, and secondary rupture. The overall mortality, aortic-related mortality, and reintervention rates were also analyzed. RESULTS A total of 101 patients had undergone elective treatment by EVAS from 2013 to 2018 for infrarenal AAAs. The median follow-up was 3.75 years. Therapeutic failure was observed in 31 of the 101 patients (30.7%), with no significant difference between the in-IFU and off-IFU 2016 subgroups. Failure occurred at a median interval of 34 months from the index procedure. Of the 101 patients, 6.9% had presented with secondary rupture. Freedom from aneurysm-related mortality was 96.9% at 1 and 2 years and 89.9% at 5 years. Freedom from reintervention decreased over time: 94.7% at 1 year, 77% at 4 years, and 52.1% at 6 years. Of the 101 patients, 14 (13.9%) had undergone emergent or elective graft explantation. CONCLUSIONS EVAS performed worse than conventional endografts for several critical end points, regardless of any preoperative anatomic parameters. The incidence of therapeutic failures tended to increase over time, especially 4 years after the index procedure.
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Affiliation(s)
- Simone Quaglino
- Vascular and Endovascular Surgery Unit, Umberto I Mauriziano Hospital, Turin, Italy.
| | - Lorenzo Mortola
- Vascular and Endovascular Surgery Unit, University Hospital of Novara, Novara, Italy
| | - Emanuele Ferrero
- Vascular and Endovascular Surgery Unit, Umberto I Mauriziano Hospital, Turin, Italy
| | - Michelangelo Ferri
- Vascular and Endovascular Surgery Unit, Umberto I Mauriziano Hospital, Turin, Italy
| | | | | | | | - Andrea Ricotti
- Department of Public Health Sciences, School of Health Statistics and Biometry, University of Turin, Turin, Italy
| | - Andrea Gaggiano
- Vascular and Endovascular Surgery Unit, Umberto I Mauriziano Hospital, Turin, Italy
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Ameli-Renani S, Pavlidis V, Morgan RA. Secondary Endoleak Management Following TEVAR and EVAR. Cardiovasc Intervent Radiol 2020; 43:1839-1854. [PMID: 32778905 PMCID: PMC7649162 DOI: 10.1007/s00270-020-02572-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 06/22/2020] [Indexed: 11/01/2022]
Abstract
Endovascular abdominal and thoracic aortic aneurysm repair and are widely used to treat increasingly complex aneurysms. Secondary endoleaks, defined as those detected more than 30 days after the procedure and after previous negative imaging, remain a challenge for aortic specialists, conferring a need for long-term surveillance and reintervention. Endoleaks are classified on the basis of their anatomic site and aetiology. Type 1 and type 2 endoleaks (EL1 and EL2) are the most common endoleaks necessitating intervention. The management of these requires an understanding of their mechanics, and the risk of sac enlargement and rupture due to increased sac pressure. Endovascular techniques are the main treatment approach to manage secondary endoleaks. However, surgery should be considered where endovascular treatments fail to arrest aneurysm growth. This chapter reviews the aetiology, significance, management strategy and techniques for different endoleak types.
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Affiliation(s)
- Seyed Ameli-Renani
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Vyzantios Pavlidis
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Robert A Morgan
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, London, UK.
- Vascular & Cardiac Surgery Research Centre, St George's University of London, Cranmer Terrace, London, SW17 ORE, UK.
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Golledge J, Drovandi A, Velu R, Quigley F, Moxon J. Survival following abdominal aortic aneurysm repair in North Queensland is not associated with remoteness of place of residence. PLoS One 2020; 15:e0241802. [PMID: 33186377 PMCID: PMC7665769 DOI: 10.1371/journal.pone.0241802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/20/2020] [Indexed: 12/15/2022] Open
Abstract
Objective To assess whether survival and clinical events following elective abdominal aortic aneurysm (AAA) repair were associated with remoteness of residence in North Queensland, Australia. Methods This retrospective cohort study included participants undergoing elective AAA repair between February 2002 and April 2020 at two hospitals in Townsville, North Queensland, Australia. Outcomes were all-cause survival and AAA-related events, defined as requirement for repeat AAA repair or AAA-related mortality. Remoteness of participant’s place of residence was assessed by the Modified Monash Model classifications and estimated distance from the participants’ home to the tertiary vascular centre. Cox proportional hazard analysis examined the association of remoteness with outcome. Results The study included 526 participants undergoing elective repair by open (n = 204) or endovascular (n = 322) surgery. Fifty-four (10.2%) participants had a place of residence at a remote or very remote location. Participants' were followed for a median of 5.2 (inter-quartile range 2.5–8.3) years, during which time there were 252 (47.9%) deaths. Survival was not associated with either measure of remoteness. Fifty (9.5%) participants had at least one AAA-related event, including 30 (5.7%) that underwent at least one repeat AAA surgery and 23 (4.4%) that had AAA-related mortality. AAA-related events were more common in participants resident in the most remote areas (adjusted hazard ratio 2.83, 95% confidence intervals 1.40, 5.70) but not associated with distance from the participants’ residence to the tertiary vascular centre Conclusions The current study found that participants living in more remote locations were more likely to have AAA-related events but had no increased mortality following AAA surgery. The findings emphasize the need for careful follow-up after AAA surgery. Further studies are needed to examine the generalisability of the findings.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
- Australian Institute of Tropical Medicine, James Cook University, Townsville, Queensland, Australia
- * E-mail:
| | - Aaron Drovandi
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Australian Institute of Tropical Medicine, James Cook University, Townsville, Queensland, Australia
| | - Ramesh Velu
- The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
| | - Frank Quigley
- Mater Private Hospital, Townsville, Queensland, Australia
| | - Joseph Moxon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Australian Institute of Tropical Medicine, James Cook University, Townsville, Queensland, Australia
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43
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Blackstock CD, Jackson BM. Open Surgical Repair of Abdominal Aortic Aneurysms Maintains a Pivotal Role in the Endovascular Era. Semin Intervent Radiol 2020; 37:346-355. [PMID: 33041480 DOI: 10.1055/s-0040-1715881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Since the advent of endovascular aortic repair (EVAR) nearly three decades ago, there has been a paradigm shift in the treatment of the abdominal aortic aneurysm (AAA) to favor EVAR due to its reduced operative mortality, less invasive nature, and faster recovery times. However, more recently there has been an accumulation of data from large meta-analyses and randomized clinical trials revealing that EVAR has no survival benefit after approximately 2 years and is associated with substantially higher rates of reintervention and aneurysm rupture in the long term. These findings call into question the durability of EVAR compared with open aortic repair and emphasize the need for surgeons to remain competent with open aortic surgery in the modern era. This article will provide comprehensive review of a large body of literature comparing endovascular repair to open aortic surgery for the management of AAAs, and it will offer an overview of the open surgical repair technique for AAAs.
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Affiliation(s)
- Christopher D Blackstock
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin M Jackson
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, Pennsylvania
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44
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Golledge J, Krishna SM, Wang Y. Mouse models for abdominal aortic aneurysm. Br J Pharmacol 2020; 179:792-810. [PMID: 32914434 DOI: 10.1111/bph.15260] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/25/2020] [Accepted: 09/03/2020] [Indexed: 12/21/2022] Open
Abstract
Abdominal aortic aneurysm (AAA) rupture is estimated to cause 200,000 deaths each year. Currently, the only treatment for AAA is surgical repair; however, this is only indicated for large asymptomatic, symptomatic or ruptured aneurysms, is not always durable, and is associated with a risk of serious perioperative complications. As a result, patients with small asymptomatic aneurysms or who are otherwise unfit for surgery are treated conservatively, but up to 70% of small aneurysms continue to grow, increasing the risk of rupture. There is thus an urgent need to develop drug therapies effective at slowing AAA growth. This review describes the commonly used mouse models for AAA. Recent research in these models highlights key roles for pathways involved in inflammation and cell turnover in AAA pathogenesis. There is also evidence for long non-coding RNAs and thrombosis in aneurysm pathology. Further well-designed research in clinically relevant models is expected to be translated into effective AAA drugs.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia.,The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - Smriti Murali Krishna
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia.,The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - Yutang Wang
- Discipline of Life Sciences, School of Health and Life Sciences, Federation University Australia, Ballarat, Victoria, Australia
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Kyriacou H, Mostafa AMHAM, Sumal AS, Hellawell HN, Boyle JR. Abdominal aortic aneurysms part two: Surgical management, postoperative complications and surveillance. J Perioper Pract 2020; 31:319-325. [PMID: 32895001 PMCID: PMC8406374 DOI: 10.1177/1750458920947352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Large, symptomatic and ruptured abdominal aortic aneurysms are usually treated surgically if patients are deemed fit enough. This may be achieved through endovascular or open surgical repair. The type of treatment that a patient receives is dependant on many factors, such as the rupture status of the aneurysm. Each approach is also associated with different risks and postoperative complications. Multiple guidelines exist to inform the surgical management of abdominal aortic aneurysms. This literature review combines these recommendations and explores the evidence upon which they are based. In addition, it highlights the key perioperative considerations that need to be considered in cases of unruptured and ruptured abdominal aortic aneurysms.
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Affiliation(s)
- Harry Kyriacou
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Ahmed M H A M Mostafa
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Anoop S Sumal
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Holly N Hellawell
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Jonathan R Boyle
- Cambridge University Hospitals, NHS Foundation Trust, Cambridge Vascular Unit, Cambridge, Cambridgeshire, UK
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46
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Lessons Learned from Open Surgical Conversion after Failed Previous EVAR. Ann Vasc Surg 2020; 71:356-369. [PMID: 32890649 DOI: 10.1016/j.avsg.2020.08.122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Delayed open conversion (OpC) after endovascular aortic aneurysm repair (EVAR) is becoming increasingly common worldwide. We reviewed our experience to characterize the perioperative spectrum of OpC repairs. MATERIALS AND METHODS A retrospective analysis of a prospectively maintained institutional database to identify patients who underwent late OpC after failed EVAR was performed. Patient and aneurysm baseline characteristics, mechanism of failure, perioperative details, including type of repair/complications/survival, and late outcomes were examined. RESULTS From January 2003 to January 2020, 38 male patients (mean age, 75 ± 7 years; range, 60-90) required late OpC. Interval time from initial EVAR to OpC was 63.6 ± 33.8 months (range, 17-120). Mean diameter of the aneurysms was 82.2 ± 22.1 mm before OpC compared with 62.9 ± 13 mm before endograft implantation. Mechanisms of failure were type Ia, Ib, II, and III endoleaks in 14 (36.8%), 9 (23.7%), 4 (10.5%), and 1 (2.6%) patient(s), respectively; infection in 3 (7.9%), leg ischemia in 2 (5.3%), and multiple causes in 5 (13.2%) patients. We observed 4 (10.5%) asymptomatic, 16 (42.1%) symptomatic, and 18 (47.3%) ruptured aneurysms. Four patients (10.5%) had stable contained ruptures, whereas the remaining 13 (34.2%) and 1 additional patient (2.6%) with aortoenteric fistula presented with hemorrhagic shock (class ≥II). Total endograft explantation, endograft preservation, or proximal/distal partial graft removal was performed in 16 (42.1%), 10 (26.3%), and 2 (5.2%)/9 (23.7%) of patients, respectively. Technical success was 100%, excluding an early postaortic clamping death. Overall, 30-day mortality was 21.1% (8 of 38) and significantly higher in patients with hemorrhagic shock or hemodynamic instability at presentation (P = 0.04 and P = 0.009, respectively) and in patients who had endografts with hooks/barbs or experiencing higher postoperative complication rate (P = 0.02 and P = 0.006, respectively). By definition, procedure success was 81.1%. Mean follow-up was 37.6 ± 39.8 months. By the end of the study, we recorded 11 deaths (2 were aneurysm related). CONCLUSIONS Despite high technical success, OpC has a significant mortality in patients presenting with hemorrhagic shock and had active fixation endografts or experiencing high complication rate. Many other confounding factors may play a role.
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Boutrous ML, Peterson BG, Smeds MR. Predictors of Aneurysm Sac Shrinkage Utilizing a Global Registry. Ann Vasc Surg 2020; 71:40-47. [PMID: 32889165 DOI: 10.1016/j.avsg.2020.08.110] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 05/17/2020] [Accepted: 08/10/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Aneurysm sac remodeling is a complex multifactorial process with unknown factors influencing sac regression after endovascular aortic aneurysm repair (EVAR). We sought to identify factors associated with this process by analyzing data obtained from patients treated with the GORE EXCLUDER endovascular aneurysm repair (EVAR) endoprosthesis from December 2010 to October 2016 enrolled in the Global Registry for Endovascular Aortic Treatment (GREAT). METHODS All patients enrolled in GREAT with three years CT angiography (CTA) follow-up in each of the three successive years after EVAR were included. The percentage of sac size reduction toward device diameter was calculated and used as a surrogate for sac regression with the formula used being: sac size reduction = ((AAA baseline diameter - AAA diameter at follow-up)/(AAA baseline diameter - device diameter))∗100. The cohort was divided into two groups in accordance with the percentage of aneurysm sac reduction at three years; one with the top quartile of patients and the other with the lowest three quartiles. Demographic and procedural variables were analyzed using univariate and regression modeling to determine factors predictive of sac regression. RESULTS There were 3265 subjects enrolled with follow-up as of May 2018 of which 526 (16.2%) had three years of CTA surveillance. Overall aneurysm sac size decreased from a mean of 58.0 mm (Std Dev: 10.4, range: 34.2, 100.0) to a mean of 49.3 mm (Std Dev: 14.1, range: 0, 140) for a percentage reduction toward device diameter of a mean 28.2% (Std Dev: 39.0, range: -103.7, 183.9). On multivariate logistic regression model; two factors proved to be statistically significant contributors to a larger percentage reduction in aneurysm sac: a conical neck (odds ratio [OR] = 1.64, P-value = 0.023) and a larger proximal device diameter (OR = 1.09, P-value = 0.023). On the other hand, two factors were negative predictors of sac shrinkage, namely: old age (OR = 0.96, P-value = 0.002) and larger baseline aneurysm sac diameter (OR = 0.98, P-value = 0.028). CONCLUSIONS Aneurysms with conical necks and larger proximal device neck diameters have an increased percentage change in sac size over time after EVAR. Older age and larger initial diameters of aneurysms were negatively associated with percentage change in sac size as well as sac regression. Further study is needed to determine the clinical utility of these observations and applicability across multiple endoprosthesis platforms.
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Affiliation(s)
- Mina L Boutrous
- Division of Vascular and Endovascular Surgery, Saint Louis University, Saint Louis, MO
| | - Brian G Peterson
- Department of Vascular Surgery, Mercy South Hospital, Saint Louis, MO
| | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, Saint Louis University, Saint Louis, MO.
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Spanos K, Nana P, Behrendt CA, Kouvelos G, Panuccio G, Heidemann F, Matsagkas M, Debus S, Giannoukas A, Kölbel T. Management of Abdominal Aortic Aneurysm Disease: Similarities and Differences Among Cardiovascular Guidelines and NICE Guidance. J Endovasc Ther 2020; 27:889-901. [PMID: 32813590 DOI: 10.1177/1526602820951265] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The development of endovascular techniques has improved abdominal aortic aneurysm (AAA) management over the past 2 decades. Different cardiovascular societies worldwide have recommended the endovascular approach as the standard of care in their currently available guidelines. While endovascular treatment has established its role in daily clinical practice, a new debate has arisen regarding the indications, appropriateness, limitations, and role of open surgery. To inform this debate, the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched from 2010 to May 2020; the systematic search identified 5 articles published between 2011 and 2020 by 4 cardiovascular societies and the National Institute of Health and Care Excellence (NICE). Four debatable domains were assessed and analyzed: diagnostic methods and screening, preoperative management, indications and treatment modalities, and postoperative follow-up and endoleak management. The review addresses controversial proposals as well as widely accepted recommendations and "gray zone" issues that need to be further investigated and analyzed, such as screening in women, medical management, and follow-up imaging. While the recommendations for AAA management have significant overlap and agreement among international cardiovascular societies, the NICE guidelines diverge regarding the role of open repair in aortic disease, recommending conventional surgery in most elective cases.
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Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.,German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Petroula Nana
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Christian-Alexander Behrendt
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - George Kouvelos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Franziska Heidemann
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Sebastian Debus
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
| | - Athanasios Giannoukas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
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Natural history of isolated type II endoleaks in patients treated by fenestrated-branched endovascular repair for pararenal and thoracoabdominal aortic aneurysms. J Vasc Surg 2020; 72:44-54. [DOI: 10.1016/j.jvs.2019.09.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/13/2019] [Indexed: 11/21/2022]
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50
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Chastant R, Canaud L, Ozdemir BA, Aubas P, Molinari N, Picard E, Branchereau P, Marty-Ané CH, Alric P. Elective late open conversion after endovascular aneurysm repair is associated with comparable outcomes to primary open repair of abdominal aortic aneurysms. J Vasc Surg 2020; 73:502-509.e1. [PMID: 32473342 DOI: 10.1016/j.jvs.2020.05.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 05/06/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Three of four patients with infrarenal abdominal aortic aneurysm are now treated with endovascular aneurysm repair (EVAR). The incidence of secondary procedures and surgical conversions is increasing for a population theoretically unfit for open surgery. The indications and outcomes of late open surgical conversions after EVAR in a high-volume tertiary vascular unit are reported. METHODS This retrospective single-center study includes all patients who underwent a late open conversion between January 1996 and July 2018. Data were collected from records on patient demographics, operative indications, surgical strategy, perioperative outcomes, and medium-term survival. RESULTS Sixty-two consecutive patients (88.7% male) with a mean age of 77.5 years are included. The median duration since index EVAR was 38.5 months; 65% of stent grafts requiring late open conversion had suprarenal fixation. Indications included 22.6% type IA, 16.1% type IB, and 45.2% type II endoleaks; 12.9% graft thrombosis; and 14.5% endoprosthesis infection. Complete endograft explantation was performed in 37.1% of patients and a partial explantation in 54.8%, whereas 8.1% of stent grafts were wholly preserved in situ. Overall 30-day mortality was 12.9% (n = 8) in the cohort and 2.7% for elective patients. The all-cause morbidity rate was 40.1%, and the median length of hospital stay was 9 days. After follow-up of 28.4 months (range, 1.8-187.3 months), all-cause survival was 58.8%. Avoidance of aortic clamping (P = .006) and elective procedures (P = .019) were associated with a significant reduction in the length of hospital stay. Moreover, the 30-day mortality (P = .002), occurrence of postoperative renal dysfunction (P = .004), and intestinal ischemia (P = .017) were increased in the emergency setting. Excluding cases with rupture or infection, survival estimates were 97%, 97%, and 71% at 1 year, 2 years, and 5 years, respectively. CONCLUSIONS Technically more complex than primary open surgery, late open conversion is a procedure that generates an acceptable perioperative risk when it is performed in a high-volume aortic surgical center. Elective open conversion is associated with excellent early and late outcomes. Endograft preservation strategies decrease perioperative morbidity.
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Affiliation(s)
- Robin Chastant
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.
| | - Ludovic Canaud
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Baris Ata Ozdemir
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France; Vascular and Endovascular Department, North Bristol NHS Trust and University of Bristol, Bristol, United Kingdom
| | - Pierre Aubas
- Department of Medical Information, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Nicolas Molinari
- Department of Medical Information, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Eric Picard
- Department of Vascular and Thoracic Surgery, Caremeau Hospital, Nimes, France
| | - Pascal Branchereau
- Department of Vascular and Thoracic Surgery, Caremeau Hospital, Nimes, France
| | - Charles-Henri Marty-Ané
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Pierre Alric
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
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