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Mathisen SR, Berge ST. A Single Centre Long Term Follow Up of the Nellix Endovascular Aneurysm Sealing System. Eur J Vasc Endovasc Surg 2024; 67:747-753. [PMID: 37951384 DOI: 10.1016/j.ejvs.2023.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 10/20/2023] [Accepted: 11/08/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVE To evaluate the clinical performance at long term follow up of endovascular aneurysm sealing (EVAS, Endologix Inc. Nellix, Irvine, CA, USA) in the treatment of abdominal aortic aneurysm (AAA). METHODS Observational, prospective, single centre study of primary AAA interventions with EVAS (n = 117) from November 2013 to November 2016. Endpoints were primary technical success, Nellix device failure, freedom from open surgical conversion (OSC), freedom from secondary intervention, sac rupture, total mortality, and aneurysm related mortality at long term follow up. RESULTS The median age was 75 years (interquartile range [IQR] 70, 81 years) and 83% were male. The median AAA diameter was 58 mm (IQR 54, 60 mm). The median length of follow up was 6.2 years (IQR 5.6, 6.8 years). Primary technical success was 100%. Median time to Nellix failure was 5.6 years (IQR 3.3, 7.4 years). Freedom from Nellix failure at five and seven years was 54% (95% confidence interval [CI] 54.2 - 63.8%) and 36% (95% CI 22.3 - 49.7%), respectively. Freedom from OSC at five and seven years was 63% (95% CI 53.2 - 72.8%) and 59% (95% CI 47 - 71%), respectively. The secondary intervention rate was 11.4/100 person years. Freedom from secondary intervention at five and seven years was 52% (95% CI 42.2 - 61.8%) and 51% (95% CI 41.2 - 60.8%), respectively. The cumulative mortality rate at five and seven years was 36% and 54%, respectively. Secondary sac rupture occurred in 9.4% (11/117) with a rate of 2/100 person years. Aneurysm related mortality was 12% (14/117) with a rate of 2.5/100 person years. The median survival was four years (IQR 3, 5.6 years). Thirty day mortality for acute OSC was 67% (n = 3) and 17.1% (6/35) for elective OSC. CONCLUSION Long term follow up showed an increased failure rate. Diligent surveillance after endovascular AAA treatment is mandatory, especially when promising new devices are put into clinical use.
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Affiliation(s)
- Sven R Mathisen
- Department of Vascular Surgery, Innlandet Hospital Trust, Hamar, Norway.
| | - Simen T Berge
- Department of Vascular Surgery, Innlandet Hospital Trust, Hamar, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
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Van Den Ham LH, Lazarian T, Groot Jebbink E, Lardenoije JW, Zeebregts CJ, Reijnen MMPJ. Evaluation of Electrocardiogram-Gated Computed Tomography Angiography to Quantify Changes in Geometry and Dynamic Behavior during the Cardiac Cycle of the Nellix Endovascular Sealing System. Radiol Res Pract 2023; 2023:3721185. [PMID: 37388254 PMCID: PMC10307170 DOI: 10.1155/2023/3721185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/01/2023] [Accepted: 06/15/2023] [Indexed: 07/01/2023] Open
Abstract
Background The Nellix endovascular sealing system (EVAS) was a unique concept with regard to its sealing concept that failed, related to high migration rates. We investigated the changes in aortoiliac morphology during the cardiac cycle before and after EVAS using electrocardiography (ECG)-gated CT. Methods Eight patients scheduled for EVAS were prospectively enrolled. ECG-gated CT scans were made pre- and postoperatively. Measurements were performed in the mid-systolic and mid-diastolic phases. Endpoints were changes in infrarenal aortoiliac morphology postoperatively compared to preoperatively and their changes in the cardiac cycle. Results Both pre- and postoperatively, there were no changes during the cardiac cycle. EVAS caused an increase in neck diameter and surface in both phases (p < 0.001). EVAS increased the luminal AAA volume (p < 0.001), with a decrease in thrombus volume (p < 0.001) in both phases and an increase in total volume (p < 0.001) in the systolic phase. During follow-up, one patient presented with >5 mm migration. There were no differences in the movements of this patient compared to the remaining patients. Conclusion The cardiac cycle had a very limited effect on the aortoiliac dynamics before and after EVAS and, therefore, there is probably not a role for ECG-gated CT in enhanced surveillance programs. EVAS itself has a significant impact on anatomy, particularly the neck diameter, length, and volumes of the AAA.
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Affiliation(s)
| | | | - Erik Groot Jebbink
- Department of Surgery, Rijnstate, Arnhem, Netherlands
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, Netherlands
| | | | - Clark J. Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Michel M. P. J. Reijnen
- Department of Surgery, Rijnstate, Arnhem, Netherlands
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, Netherlands
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Rastogi V, O'Donnell TFX, Solomon Y, Varkevisser RRB, Patel PB, Carpenter JP, de Bruin JL, Reijnen MMPJ, Verhagen HJM, Schermerhorn ML. Mortality analysis of endovascular aneurysm sealing versus endovascular aneurysm repair. J Vasc Surg 2023; 77:731-740.e1. [PMID: 36651654 PMCID: PMC9974809 DOI: 10.1016/j.jvs.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/21/2022] [Accepted: 10/25/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Endovascular aneurysm sealing (EVAS), using the Nellix endovascular aneurysm sealing system, has been associated with high reintervention and migration rates. However, prior reports have suggested that EVAS might be related to a lower all-cause mortality compared with endovascular aneurysm repair (EVAR). In the present study, we examined the 5-year all-cause mortality trends after EVAS and EVAR. METHODS We compared the 333 EVAS patients in the EVAS-1 Nellix U.S. investigational device exemption trial with 16,497 infrarenal EVAR controls from the Vascular Quality Initiative, treated between 2014 and 2016, after applying the exclusion criteria from the investigational device exemption trial (ie, hemodialysis, creatinine >2.0 mg/dL, rupture). As a secondary analysis, we stratified the patients by aneurysm diameter (<5.5 cm and ≥5.5 cm). We calculated propensity scores after adjusting for demographics, comorbidities, and anatomic characteristics and applied inverse probability weighting to compare the risk-adjusted long-term mortality using Kaplan-Meier and Cox regression analyses. RESULTS After weighting, the EVAS group had experienced similar 5-year mortality compared with the controls from the Vascular Quality Initiative (EVAS vs EVAR, 18% vs 14%; hazard ratio [HR], 1.1; 95% confidence interval [CI], 0.71-1.7; P = .70). The subgroup analysis demonstrated that for patients with an aneurysm diameter of <5.5 cm, EVAS was associated with higher 5-year mortality compared with EVAR (19% vs 11%; HR, 2.4; 95% CI, 1.7-4.7; P = .013). In patients with an aneurysm diameter of ≥5.5 cm, EVAS was associated with lower mortality within the first 2 years (2-year mortality: HR, 0.29; 95% CI, 0.13-0.62; P = .002). However, compared with EVAR, EVAS was associated with higher mortality between 2 and 5 years (HR, 1.9; 95% CI, 1.2-3.0; P = .005), with no mortality difference at 5 years (18% vs 17%; HR, 0.82; 95% CI, 0.4-1.4; P = .46). CONCLUSIONS Within the overall population, EVAS was associated with similar 5-year mortality compared with EVAR. EVAS was associated with higher mortality for those with small aneurysms (<5.5 cm). For those with larger aneurysms (≥5.5 cm), EVAS was initially associated with lower mortality within the first 2 years, although this advantage was lost thereafter, with higher mortality after 2 years. Future studies are required to evaluate the specific causes of death and to elucidate the potential beneficial mechanism behind sac obliteration that leads to this potential initial survival benefit. This could help guide the development of future grafts with better proximal fixation and sealing that also incorporate sac obliteration.
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Affiliation(s)
- Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Yoel Solomon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Rens R B Varkevisser
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jeffrey P Carpenter
- Division of Vascular Surgery, Cooper Medical School of Rowan University, Camden, NJ
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Michel M P J Reijnen
- Department of Surgery, Rijnstate, Arnhem, The Netherlands; Multi-Modality Medical Imaging Group, University of Twente, Enschede, The Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Volpe P, Alberti A, Alberti V, Massara M. A Case of Late Type Ia Endoleak After Endovascular Aneurysm Sealing Using the Nellix System: Proximal Extension with Triple Chimney and Gutter Endoleak Embolization. Ann Vasc Dis 2021; 14:393-395. [PMID: 35082948 PMCID: PMC8752914 DOI: 10.3400/avd.cr.21-00092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/09/2021] [Indexed: 11/29/2022] Open
Abstract
An 87-year-old man, who submitted to endovascular aneurysm sealing (EVAS) on 2017, presented a type Ia endoleak 2 years later, with enlargement of the aneurysmal sac. We planned an endovascular procedure of correction consisting of a proximal extension through two covered stent grafts deployed into the previous Nellix stent grafts, with associated triple chimney. However, 3 months later, he had a further 5 mm aneurysmal sac enlargement. He was submitted to angiography with coil embolization of gutters, obtaining a successfully result. At 1 and 3 months, he is free from endoleak, with a stable aneurysmal diameter.
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Affiliation(s)
- Pietro Volpe
- Vascular and Endovascular Surgery Unit, Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli,"Reggio Calabria, Italy
| | - Antonino Alberti
- Vascular and Endovascular Surgery Unit, Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli,"Reggio Calabria, Italy
| | - Vittorio Alberti
- Vascular and Endovascular Surgery Unit, Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli,"Reggio Calabria, Italy
| | - Mafalda Massara
- Vascular and Endovascular Surgery Unit, Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli,"Reggio Calabria, Italy
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Innovative solutions for endovascular aneurysm sealing-delayed Nellix type 1a endoleak. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:599-604. [PMID: 34693086 PMCID: PMC8515095 DOI: 10.1016/j.jvscit.2021.06.012] [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: 04/27/2021] [Accepted: 06/14/2021] [Indexed: 11/24/2022]
Abstract
A delayed Nellix (Endologix, Irvine, Calif) type 1a endoleak from endovascular aneurysm sealing (EVAS) is particularly challenging to treat owing to the restrictions and scarcity of the technical options available. We have described two viable endovascular solutions, with and without the availability of the Nellix endograft inventory. A Nellix-in-Nellix apparatus with multivisceral chimney, covered stent extensions and internal reinforcements can be used if Nellix endografts are available (patient 1). In the absence of Nellix endografts, we used a Viabahn-in-Nellix apparatus, also with multiple chimney stents, as an alternative and timely treatment for patient 2. Our patients remained well and free of endoleaks at 19 and 11 months after treatment.
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Pleban E, Michalak J, Iwanowski J, Szopinski P. The Dilemma after Sealing an Endovascular Aortic Aneurysm - Three Ways Out. Zentralbl Chir 2021; 146:498-505. [PMID: 34666357 DOI: 10.1055/a-1644-1650] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Endovascular aneurysm sealing (EVAS) was commercially introduced in 2013. The initial results of EVAS were positive, leading to its widespread use. The mid- and long-term reports showed greater than expected rates of migration, which led to a recall of the device. In the present article, we describe our experience in managing type Ia endoleaks and migration occurring with the Nellix system in three different ways: open repair with Nellix explantation, Nellix-in-Nellix application (NINA technique), and the use of the multibranched Colt device originally dedicated to the treatment of thoracoabdominal aneurysms. MATERIALS AND METHODS From February 2014 to June 2021, we performed 20 procedures for failed EVAS or ChEVAS (migration, type Ia endoleak, secondary aneurysm rupture). All patients treated for EVAS failure were male, aged 65 - 79. RESULTS Seven Nellix explantations were performed. Three patients were admitted to our hospital with ruptured aneurysms that occurred 3 weeks to 4 years (mean 124 weeks) after EVAS, and another four with type Ia endoleak. In all but one case, removal of the Nellix system was easy. In two patients, tube grafts were implanted and in the remaining five cases, bifurcated grafts were implanted. In four patients, graft legs were anastomosed with the internal iliac arteries. One patient with secondary aneurysm rupture died from multiorgan failure on the 4th postoperative day. In two cases, transient renal failure was noticed in the perioperative period. All patients were admitted to the intensive care unit for 1 to 4 days (mean 2 days). The mean hospital stay was 9 days. All patients stayed in follow-up (3 - 56 months), but no other complications occurred. Eight patients were treated with the NINA technique: five for distal migration of the Nellix and three for failed ChEVAS. Four patients had a NINA procedure performed with three chimneys, three with two and one with one chimney. In one case, two iliac limbs were implanted to avoid kinking of the external iliac arteries. The median hospitalization time after the procedure was 9 days (range 3 - 12). Four patients developed transient acute renal insufficiency in the perioperative period. The follow-up ranged between 4 and 72 months. In one patient, deterioration of preexisting chronic renal insufficiency developed 5 months after the procedure, but dialysis was not required. One patient died from exacerbation of heart failure 7 months after the NINA procedure. The Colt device was implanted in five patients for the treatment of distal migration with type Ia endoleaks. None of the patients developed any signs of spinal cord ischemia. All patients were admitted to the intensive care unit for 1 or 2 days. In two cases, transient acute renal failure was noticed in the perioperative period. The mean hospital stay was 9 days. All patients remained in follow-up (6 - 22 months). In one case, the occlusion of the celiac trunk branch was found in contrast computed tomography 1 month after implantation of the Colt device, but without any symptoms. No other complications occurred. CONCLUSIONS Normal strategies for the management of complications for late failure of EVAR, including stent-graft extensions, are not suitable after EVAS; therefore, alternatives are necessary. Conversion to open repair carries an extensive burden on the patient, so it is not recommended for patients with high surgical risk. The use of a Nellix-in-Nellix application to treat late failure of EVAS is not within the instructions for use but could be an effective strategy for a type Ia endoleak with or without migration. The use of this technique has been extremely limited since the Nellix system was recalled from the market. The use of the Colt multibranched device may be an alternative option, but due to the small number of patients, this method needs further evaluation.
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Affiliation(s)
- Eliza Pleban
- Clinic of Vascular Surgery, Institute of Hematology and Blood Transfusion, Warszawa, Poland
| | - Jacek Michalak
- Clinic of Vascular Surgery, Institute of Hematology and Blood Transfusion, Warszawa, Poland
| | - Jaroslaw Iwanowski
- Clinic of Vascular Surgery, Institute of Hematology and Blood Transfusion, Warszawa, Poland
| | - Piotr Szopinski
- Clinic of Vascular Surgery, Institute of Hematology and Blood Transfusion, Warszawa, Poland
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Lin JX, Taylor S, Hidajat C, Hill A. Difficult diagnosis and management of a complicated Nellix graft infection. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:417-420. [PMID: 34278074 PMCID: PMC8261550 DOI: 10.1016/j.jvscit.2021.04.021] [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: 01/03/2021] [Accepted: 04/26/2021] [Indexed: 11/16/2022]
Abstract
An 81-year-old man, with a complex vascular surgical history, presents with sepsis from an infected Nellix stent-graft. He required an urgent laparotomy, explantation of the graft, and extra-anatomical repair. Although now widely used for this indication, the preoperative 18F-fluorodeoxyglucose positron emission tomography/computed tomography was nondiagnostic for his stent-graft infection. We describe our management of a complicated Nellix graft infection and discuss the utility of positron emission tomography/computed tomography for stent-graft infections.
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Affiliation(s)
- Jin Xin Lin
- Department of Vascular Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Sam Taylor
- Department of Vascular Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Cassandra Hidajat
- Department of Vascular Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Andrew Hill
- Department of Vascular Surgery, Auckland City Hospital, Auckland, New Zealand
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Mortola L, Ferrero E, Quaglino S, Ferri M, Viazzo A, Manzo P, Gaggiano A. Management of Nellix migration and type Ia endoleak from proximal endovascular aneurysm sealing relining to late open conversion. J Vasc Surg 2021; 74:1204-1213. [PMID: 33684472 DOI: 10.1016/j.jvs.2021.02.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 02/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite promising early results, mid-term failures of the Nellix endovascular aneurysm sealing (EVAS) system (Endologix Inc, Irvine, Calif) have been reported at higher than expected rates. The management of proximal endoleaks and migration differs from those after conventional endovascular aortic aneurysm repair (EVAR) owing to the peculiar design of the Nellix device. In the present study, we report a monocentric experience in the management of EVAS complications using various techniques. We also performed a comprehensive review of the relevant literature on both open surgical and endovascular management of proximal failure of EVAS from the MEDLINE database. METHODS We retrospectively analyzed the reinterventions for type Ia endoleak and migration after elective infrarenal EVAS at our institution. We collected preoperative, intraoperative, and follow-up data. Open and endovascular techniques are described. Overall survival, aortic-related mortality, and the technical success rate (rate of exclusion of endoleaks) with endovascular techniques were the primary outcomes. RESULTS We performed 101 infrarenal elective EVAS procedures from 2013 to 2018. Of the 101 patients, 20 (19.8%) had required reintervention for proximal sealing failure. The indications were type Ia (Is2, Is3) endoleak, migration >5 mm, sac expansion >5 mm, and secondary rupture. Of the 20 patients, 6 (30%) were treated with endovascular techniques-2 with a chimney Nellix-in-Nellix application and 4 with proximal relining with a covered stent. The remaining 14 patients (70%) were treated with late open conversion (OC). The average time from EVAS to reintervention was 36.1 months (range, 3-65 months). Six patients (30%) had undergone OC in an emergent setting because of secondary rupture. The technical success rate for the patients treated with endovascular reinterventions was 100%. The 30-day mortality was 20% (4 of 20), all emergent cases (four of six emergent repairs; 67%). The overall survival for the 20 patients was 75% (n = 15) at a mean follow-up of 15.1 months (range, 2-47 months). One patient had died after 7 months of non-aortic-related causes. CONCLUSIONS The high reintervention rate of the Nellix graft mandates careful evaluation for its further use with the revised instructions for use, and it should not be used off-label. OC remains the strategy of choice when managing Nellix proximal sealing failures in fit patients. Chimney Nellix-in-Nellix application and transcatheter embolization are feasible alternative techniques. Proximal relining also appears to be an effective alternative to more complex interventions, although it requires further studies for validation.
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Affiliation(s)
- Lorenzo Mortola
- Vascular and Endovascular Surgery Unit, University Hospital of Novara, Novara, Italy.
| | - Emanuele Ferrero
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Simone Quaglino
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Michelangelo Ferri
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Andrea Viazzo
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Paola Manzo
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
| | - Andrea Gaggiano
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Turin, Italy
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Hatzl J, Peters AS, Pfeiffer S, Meisenbacher K, Bischoff MS, Böckler D. Midterm single-center results after endovascular aneurysm sealing reveal a high rate of stent graft migration, secondary aneurysm ruptures, and device-related reinterventions. J Vasc Surg 2021; 74:738-745.e3. [PMID: 33639234 DOI: 10.1016/j.jvs.2021.02.017] [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: 10/19/2020] [Accepted: 02/11/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To report procedural results and mid-term follow-up outcomes of patients treated with endovascular aneurysm sealing (EVAS) for abdominal aortic disease. METHODS In this retrospective observational study, all patients treated with EVAS between March 2013 and January 2018 for abdominal aortic aneurysm (AAA) or abdominal penetrating aortic ulcer were included. The datasets included demographics, aneurysm morphology, and procedural and clinical surveillance outcomes. Furthermore, patients treated within the original instructions for use (IFU-group) were compared with patients treated outside the IFU (non-IFU-group) with regard to survival, reintervention-free survival, freedom from type I endoleak, and freedom from stent graft migration. RESULTS Seventy patients were included (67 male; median age, 72.5 years). Sixty-five patients were treated for AAA and 5 patients for abdominal penetrating aortic ulcer. Sixty-nine cases were treated electively (98.6%). Technical success was achieved in 68 cases (97.1%). The median clinical follow-up was 50.5 months (interquartile range, 29.3-62.7 months) with a median computed tomography angiographic follow-up of 38.5 months (interquartile range, 17.1-60.2 months). There were five deaths during the study period (7.1%), four of which were aneurysm related (5.7%). Five secondary AAA ruptures were detected (7.1%). Overall, 25 of 70 patients (35.7%) underwent 35 reinterventions, mostly owing to thrombotic complications (18.6%), stent graft migration (17.1%), and type I endoleak (12.9%). Fifteen patients were treated outside of the IFU (non-IFU-group) (21.4%). The estimated reintervention-free survival for the entire cohort at 30 days and 1, 3, and 5 years was 94.3%, 88.5%, 72%, and 56.9%, respectively. Freedom from stent graft migration at 1, 3, and 5 years was 98.6%, 82.0%, and 47.3%, respectively. The estimated freedom from type I endoleak at 30 days and 1, 3, and 5 years in the IFU-group was 100%, 100%, 94.9% and, 91.1% and significantly different when compared with the non-IFU-group with 79.5%, 72.2%, 72.2%, and 72.2% (P = .012). CONCLUSIONS Although the technical and initial results were satisfying, the mid-term results were disappointing. The enforcement of a close follow-up protocol for all patients treated with EVAS, especially vigilant for stent graft migration to prevent secondary type I endoleak and rupture, is strongly recommended.
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Affiliation(s)
- Johannes Hatzl
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany.
| | - Andreas S Peters
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Sabine Pfeiffer
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Katrin Meisenbacher
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Moritz S Bischoff
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
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Battista F, Ficarelli R, Perrotta A, Gualtieri P, Casciola CM, Romano GP, Taurino M. The Fluid-Dynamics of Endo Vascular Aneurysm Sealing (EVAS) System failure. Cardiovasc Eng Technol 2021; 12:300-310. [PMID: 33565030 PMCID: PMC8169503 DOI: 10.1007/s13239-021-00520-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/13/2021] [Indexed: 12/14/2022]
Abstract
Purpose The main objective of this work is to investigate hemodynamics phenomena occurring in EVAS (Endo Vascular Aneurysm Sealing), to understand if and how they could lead to type 1a endoleaks and following re-intervention. To this aim, methods based on computational fluid mechanics are implemented as a tool for checking the behavior of a specific EVAS configuration, starting from the post-operative conditions. Pressure and velocity fields are detailed and compared, for two configurations of the Nellix, one as attained after correct implantation and the other in pathological conditions, as a consequence of migration or dislocation of endobags. Methods The computational fluid dynamics (CFD) approach is used to simulate the behavior of blood within a segment of the aorta, before and after the abdominal bifurcation. The adopted procedure allows reconstructing the detailed vascular geometry from high-resolution computerized tomography (CT scan) and generating the mesh on which the equations of fluid mechanics are discretized and solved, in order to derive pressure and velocity field during heartbeats. Results The main results are obtained in terms of local velocity fields and wall pressures. Within the endobags, velocities are usually quite regular during the whole cardiac cycle for the post-implanted condition, whereas they are more irregular for the migrated case. The largest differences among the two cases are observed in the shape and location of the recirculation region in the rear part of the aorta and the region between the endobags, with the formation of a gap due to the migration of one or both of the two. In this gap, the pressure fields are highly different among the two conditions, showing pressure peaks and pressure gradients at least four times larger for the migrated case in comparison to the post-implanted condition. Conclusions In this paper, the migration of one or both endobags is supposed to be related to the existing differential pressures acting in the gap formed between the two, which could go on pushing the two branches one away from the other, thus causing aneurysm re-activation and endoleaks. Regions of flow recirculation and low-pressure drops are revealed only in case of endobag migration and in presence of an aneurysm. These regions are supposed to lead to possible plaque formation and atherosclerosis.
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Affiliation(s)
- F Battista
- Department of Mechanical and Aerospace Engineering, Sapienza University of Roma, Roma, Italy.
| | - R Ficarelli
- Department of Clinical and Molecular Medicine, Sapienza University of Roma, Roma, Italy
| | - A Perrotta
- Department of Mechanical and Aerospace Engineering, Sapienza University of Roma, Roma, Italy
| | - P Gualtieri
- Department of Mechanical and Aerospace Engineering, Sapienza University of Roma, Roma, Italy
| | - C M Casciola
- Department of Mechanical and Aerospace Engineering, Sapienza University of Roma, Roma, Italy
| | - G P Romano
- Department of Mechanical and Aerospace Engineering, Sapienza University of Roma, Roma, Italy
| | - M Taurino
- Department of Clinical and Molecular Medicine, Sapienza University of Roma, Roma, Italy
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Martinelli O, Alunno A, Gattuso R, Girolamo AD, Luigi Irace. Nellix endovascular aneurysm-sealing system: a single-center experience and review of current evidence. Future Cardiol 2020; 17:875-884. [PMID: 33269638 DOI: 10.2217/fca-2020-0134] [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: 11/21/2022] Open
Abstract
Aims: We report the 6-year results of our use of the Nellix® endovascular aneurysm sealing system. Materials & methods: This is a retrospective review of patients we treated from 2013 to 2019. The outcomes described include technical success rate, mortality, all procedure-related complications, reinterventions, open surgical conversion and secondary sac rupture. Results & conclusions: A total of 68 patients were treated. Mortality was 2.9%. Secondary interventions were carried out for distal embolization (3), stent occlusion (1), pseudoaneurysm (1) and endoleak (5). Open surgical conversion was required in 6.4% of cases. Medium- and long-term complications of EVAS occurred more frequently than expected. Because the durability of endovascular aneurysm sealing is questionable, strict postoperative surveillance of Nellix is crucial to identify features of failure.
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Affiliation(s)
- Ombretta Martinelli
- Department of Vascular Surgery- "Sapienza" University of Rome - Policlinico "Umberto I", Viale del Policlinico, 155, 0016, Rome, Italy
| | - Alessia Alunno
- Department of Vascular Surgery- "Sapienza" University of Rome - Policlinico "Umberto I", Viale del Policlinico, 155, 0016, Rome, Italy
| | - Roberto Gattuso
- Department of Vascular Surgery- "Sapienza" University of Rome - Policlinico "Umberto I", Viale del Policlinico, 155, 0016, Rome, Italy
| | - Alessia Di Girolamo
- Department of Vascular Surgery- "Sapienza" University of Rome - Policlinico "Umberto I", Viale del Policlinico, 155, 0016, Rome, Italy
| | - Luigi Irace
- Department of Vascular Surgery- "Sapienza" University of Rome - Policlinico "Umberto I", Viale del Policlinico, 155, 0016, 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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Zerwes S, Kiessling J, Liebetrau D, Jakob R, Gosslau Y, Bruijnen HK, Hyhlik-Duerr A. Open Conversion After Endovascular Aneurysm Sealing: Technical Features and Clinical Outcomes in 44 Patients. J Endovasc Ther 2020; 28:332-341. [DOI: 10.1177/1526602820971830] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose To evaluate the technical features and clinical results after open conversion for complications following endovascular aneurysm sealing (EVAS). Materials and Methods From July 2013 to February 2020, 44 patients (mean age 72±8 years; 36 men) underwent an open conversion due to EVAS complications in a single center. Data were collected on patient characteristics, reasons for conversion, characteristics and duration of the procedure, condition of the polymer, blood loss, time in the intensive care unit (ICU), and intra/postoperative complications. The main outcome measure was mortality at 30 days and in follow-up. Data are presented as the median (IQR) and absolute range. Results On average, the open conversion took place 3 years after the initial EVAS implantation [median 37 months (IQR 23, 50); range 0–64]. Most patients were converted due migration (82%), aneurysm growth (77%), and/or endoleak (75%), with 21 patients (48%) having all 3 events. Less frequent diagnoses were aneurysm rupture (n=7), aortic infection (n=3), technical failure during implantation (n=2), and graft thrombosis (n=1). The majority of patients (n=26) were asymptomatic and converted electively, but 9 were operated on urgently and 9 emergently (7 late rupture and 2 due to technical failure). The median procedure duration was 178 minutes (IQR 149, 223; range 87–417), the median blood loss was 1100 mL (IQR 600, 2600; range 300–5000). Polymer degradation was mentioned in the operative reports of 18 cases (41%). Patients stayed a median of 3 days (IQR 2, 7; range 1–35) in the ICU, while the median length of stay in the hospital was 14 days (IQR 10, 20; range 0–93). The 30-day mortality was 23% (n=10). During a median follow-up of 3 months (IQR 0, 11; range 0–38), no additional deaths occurred, but 12 patients suffered from an adverse event. There were 3 cases of wound dehiscence after laparotomy, 2 cases of leg ischemia, 2 cases of renal failure, and individual cases of urinary obstruction, urinoma, paralytic ileus, gastrointestinal bleeding, and postoperative delirium. A non-elective setting was associated with a significantly increased mortality of 33% in urgent cases and 56% in emergent cases (p=0.007). Based on these results an algorithm for the management of EVAS complications was developed. Conclusion The significantly increased mortality associated with nonelective conversions highlights the need for active surveillance. The presented algorithm offers a structured tool to avoid emergency conversions.
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Affiliation(s)
- Sebastian Zerwes
- Clinic for Vascular and Endovascular Surgery, Medizinische Fakultät, Universität Augsburg, Germany
| | - Johanna Kiessling
- Clinic for Vascular and Endovascular Surgery, Medizinische Fakultät, Universität Augsburg, Germany
| | - Dominik Liebetrau
- Clinic for Vascular and Endovascular Surgery, Medizinische Fakultät, Universität Augsburg, Germany
| | - Rudolf Jakob
- Clinic for Vascular and Endovascular Surgery, Medizinische Fakultät, Universität Augsburg, Germany
| | - Yvonne Gosslau
- Clinic for Vascular and Endovascular Surgery, Medizinische Fakultät, Universität Augsburg, Germany
| | - Hans-Kees Bruijnen
- Clinic for Vascular and Endovascular Surgery, Medizinische Fakultät, Universität Augsburg, Germany
| | - Alexander Hyhlik-Duerr
- Clinic for Vascular and Endovascular Surgery, Medizinische Fakultät, Universität Augsburg, Germany
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Dzieciuchowicz Ł, Tomczak J, Strauss E, Oszkinis G. Mid-Term Results of Endovascular Aneurysm Sealing in the Treatment of Abdominal Aortic Aneurysm With Unfavorable Morphology. Vasc Endovascular Surg 2020; 55:39-49. [PMID: 33034263 DOI: 10.1177/1538574420965736] [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: 11/16/2022]
Abstract
PURPOSE To report mid-term results of endovascular aneurysm sealing (EVAS) of abdominal aortic aneurysms (AAA) deemed unsuitable for a standard endovascular aneurysm repair (EVAR). METHODS A prospectively maintained database of 42 patients with EVAR-unfavorable anatomy treated by EVAS combined with chimney grafts in case of the proximal AAA neck shorter than 5 mm was analyzed. Early outcomes included final angiographic result, intra- and early post-operative deaths, and complications. Mid-term outcomes included all-cause mortality (ACM), aneurysm-related mortality (ARM), patency of the stents, occurrence of endoleaks, serious complications and graft failures defined as the AAA growth of more than 5 mm, type I endoleak, occlusion of the stent-graft or chimney graft, aorto-duodenal fistula, or aneurysm rupture. RESULTS The procedure was completed in all patients. Twenty-eight chimney grafts were implanted in 19 patients. Patients were followed for a median of 24 months (range 12-34 months). There were 2 intraoperative ruptures and 1 patient died in an early postoperative period. The cumulative ACM was 15, 21, and 36% at 12, 24, and 36 months, respectively, and the cumulative ARM was 8, 11, and 27% at 12, 24, and 36 months, respectively. Three out of 5 aneurysm-related deaths were due to a secondary aorto-duodenal fistula. The cumulative incidence of graft failure was 20, 27, and 42% at 12, 24, and 36 months, respectively. The cumulative incidence of an endoleak was 5, 9, and 23% at 12, 24, and 36 months, respectively. The graft failure increased significantly both ACM (p = .012) and ARM (p = .00003). The implantation of chimney grafts at the initial procedure increased ARM significantly (p = .008). The presence of an endoleak did not have any significant influence on ACM and ARM. CONCLUSION Patients treated with EVAS for AAAs with EVAR-unfavorable anatomy, especially those with chimney grafts, exhibit a high risk of graft failure and subsequent death.
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Affiliation(s)
- Łukasz Dzieciuchowicz
- Department of Vascular Surgery and Vascular Diseases, Institute of Medical Sciences, 49792University of Zielona Góra, Zielona Góra, Poland
| | - Jolanta Tomczak
- Department of Vascular and Endovascular Surgery, Angiology and Phlebology, 37807Poznan University of Medical Sciences, Poznań, Poland
| | - Ewa Strauss
- Department of Vascular and Endovascular Surgery, Angiology and Phlebology, 37807Poznan University of Medical Sciences, Poznań, Poland.,Institute of Human Genetics, Polish Academy of Sciences, Poznań, Poland
| | - Grzegorz Oszkinis
- Department of General and Vascular Surgery, University of Opole, Opole, Poland
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15
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Vento V, Lejay A, Kuntz S, Ancetti S, Heim F, Chakfé N, Gargiulo M. Current status on aortic endografts. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:544-554. [PMID: 32964901 DOI: 10.23736/s0021-9509.20.11614-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Endovascular treatment has become widespread to treat aneurysmal disease, especially located in the aorta. The modern era of abdominal aortic aneurysm repair started between 1986 and 1991, and in the last 30 years, Endovascular Treatment for abdominal aortic aneurysms evolved both due to the development of new materials and devices and the increasing appeal and effectiveness of the endovascular therapy itself. Vascular surgeons are using nowadays different solutions of Endovascular Treatment to treat all the expressions of aortic pathology (aneurysms, dissections and trauma) both in the acute and elective setting. Despite its use in every location of the aorta (the ascending aorta, the aortic arch, the thoracic aorta, thoraco-abdominal aorta, pararenal, iuxtarenal and infrarenal aortic aneurysms and iliac aneurysms), its safety and efficiency, endovascular treatment for aortic aneurysms presents some drawbacks: despite a lower short-term morbi-mortality, reinterventions and long-term patency are higher compared to open repair. In this review, we detail the most used types of endografts according to location, their performances and durability for each device. We conclude by discussing options to overcome ET limitations. Therefore, an obvious question arises: what we need in the future? What can the technological progress gives to physicians to further improve this new way of treating aorta?
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Affiliation(s)
- Vincenzo Vento
- Unit of Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy.,Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Anne Lejay
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Salomé Kuntz
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Stefano Ancetti
- Unit of Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy
| | - Frédéric Heim
- Laboratory of Physics and Textile Mechanics, University of Upper Alsace, Mulhouse, France
| | - Nabil Chakfé
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Mauro Gargiulo
- Unit of Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy -
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Proper technical procedures improved outcomes in a retrospective analysis of EVAS FORWARD IDE trial 3-year results. J Vasc Surg 2020; 72:918-930.e2. [DOI: 10.1016/j.jvs.2019.11.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 11/12/2019] [Indexed: 11/17/2022]
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17
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Cannavale A, Lucatelli P, Corona M, Nardis P, Cannavale G, De Rubeis G, Santoni M, Maher B, Catalano C, Bezzi M. Current assessment and management of endoleaks after advanced EVAR: new devices, new endoleaks? Expert Rev Cardiovasc Ther 2020; 18:465-473. [PMID: 32634069 DOI: 10.1080/14779072.2020.1792294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION In recent years there has been an increasing application of advanced EVAR techniques to tackle complex clinical and anatomical scenarios. In a bid to overcome the limitations of the traditional stent-grafts, newer EVAR endografts and techniques have been developed and introduced into clinical practice, permitting endovascular management of difficult infrarenal, juxta-renal and thoracoabdominal aneurysms for which previously there was no endovascular solution. As a consequence, we are now confronted with unique patterns of endoleak requiring customized clinical-radiological assessment and treatment. Despite the increasing body of evidence regarding new EVAR techniques and related endoleaks, current guidelines do not specifically address these issues. OBJECTIVES Our review aims to assess risk factors, development, and management strategies of these endoleaks, in the most recent infrarenal EVAR devices and in more complex fenestrated EVAR (FEVAR) and Chimney EVAR (Ch-EVAR). EXPERT OPINION Most new devices have demonstrated types of endoleaks that need specific imaging and treatment, as in EVAS, FEVAR, and ChEVAR. Knowledge of specific stent-graft characteristics and the nature of endoleaks associated with the various procedures facilitates the application of relevant useful imaging. In addition, it should aid development of a customized and practically relevant approach to patient management during intervention and follow-up.
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Affiliation(s)
- Alessandro Cannavale
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome , Rome, Italy
| | - Pierleone Lucatelli
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome , Rome, Italy
| | - Mario Corona
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome , Rome, Italy
| | - Piergiorgio Nardis
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome , Rome, Italy
| | - Giuseppe Cannavale
- Department of Radiological Sciences, "Sapienza" University of Rome , Rome, Italy
| | - Gianluca De Rubeis
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome , Rome, Italy
| | - Mariangela Santoni
- Department of Radiological Sciences, "Sapienza" University of Rome , Rome, Italy
| | - Ben Maher
- Department of Interventional Radiology, University Hospital Southampton NHS Foundation Trust , Southampton, UK
| | - Carlo Catalano
- Department of Radiological Sciences, "Sapienza" University of Rome , Rome, Italy
| | - Mario Bezzi
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome , Rome, Italy
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18
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Ascoli Marchetti A, Oddi FM, Vacca F, Orellana Dàvila B, Ippoliti A. The Safety of EVAS Surgical Conversion in a Comparative Monocentric Analysis. Ann Vasc Surg 2020; 68:310-315. [PMID: 32439532 DOI: 10.1016/j.avsg.2020.04.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Endovascular aneurysm sealing (EVAS) was a widespread technology to treat abdominal aortic aneurysm. However, the particular morphology and structure of this endoprosthesis predisposed to proximal sealing defects with a high rate of reintervention or conversion to open surgery treatments. The purpose of this article is to report our experience on late open conversion of Nellix device, compared with the previous reported experience. MATERIALS AND METHODS Between September 2013 and February 2020, eight late open surgical conversions for endoleak (EL) were performed in our center: four of these were for EVAR. Four of these were EVAS devices required explantation and were included in the study. All excisions of infected abdominal aortic endograft were excluded. RESULTS All patients were treated within the original instructions for use. Aorto-bi-iliac reconstruction was performed with a bifurcated Dacron graft in all the four cases. At 12 months Doppler ultrasonography follow-up, good results at short term with preserved primary patency and freedom of re-intervention in three cases were reported. Only one patient died 16 days after the procedure. Nevertheless, the endoprosthetic structure allows in three of our cases to clamp down the renal level, with a decrease of the time of lower limbs ischemia and greater safety of the open surgery repair procedure. CONCLUSIONS The EVAS conversion is common, and a closer follow-up is required. The most recurrent open surgery indication is its migration and the EL type 1. The procedure is influenced by multiple comorbidities; emergency graft excision appears to increase morbidity and mortality, compared with elective surgical setting.
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Affiliation(s)
| | - Fabio Massimo Oddi
- Biomedicine and Prevention Department, Vascular Surgery Unit, Rome, Italy
| | - Fabio Vacca
- Biomedicine and Prevention Department, Vascular Surgery Unit, Rome, Italy
| | | | - Arnaldo Ippoliti
- Biomedicine and Prevention Department, Vascular Surgery Unit, Rome, Italy
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19
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Sonetto A, Laukontaus S, Vikatmaa L, Aho P, Venermo M. Three-Year Results of the Nellix Endovascular Aneurysm Sealing System for Treatment of Abdominal Aortic Aneurysms in Frail Patients with Poor Anatomical Features. Scand J Surg 2020; 110:233-240. [DOI: 10.1177/1457496920917267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Endovascular aneurysm sealing represents an alternative to advanced technology devices for compromised patients with abdominal aortic aneurysms. We report our results of 15 fragile patients with very low-quality infrarenal necks treated with endovascular aneurysm sealing. Material and methods: All patients treated with Nellix device in our hospital between June 2015 and October 2016 were retrospectively reviewed. The primary endpoints are the following: overall survival and freedom from reintervention rates. The secondary endpoints are the following: technical success; 30-day mortality; abdominal aortic aneurysm–related mortality; and freedom from endoleak rate, complications, and surgical conversion rate. Results: Nellix was used in 15 patients, median age 75.5 years, of which 67% were unfit for open surgery. Mean aneurysm diameter was 60 mm. One-third (5/15) of the patients were inside the Nellix instructions for use. Technical success rate was 93.3%. No perioperative complications existed, and 30-day mortality was 0%. Median follow-up was 35 (interquartile range: 11–37) months. Survival rates at 1 and 3 years were 80% and 59.3%. Abdominal aortic aneurysm–related mortality occurred in 3 of 15 cases. Freedom from rupture rates at 1 and 3 years were 92.9% and 66%. Freedom from endoleak rates at 1 and 3 years were 92.9% and 74.5%. Freedom from reintervention rates at 1 and 3 years were 86.7% and 70.6%, with a dramatic drop to 37.1% at 4 years of follow-up. Three open surgery conversions were needed. There were no statistically significant differences in results between patients treated inside and outside instructions for use. Conclusion: The endovascular aneurysm sealing has shown encouraging short-term results, but its safety and effectiveness during time is questionable, because this system still carries high rates of reintervention, conversions for type IA endoleaks, and secondary aneurysm ruptures.
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Affiliation(s)
- A. Sonetto
- Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Department of Vascular Surgery, DIMES, Azienda Policlinico S. Orsola-Malpighi, Alma Mater Studiorum—University of Bologna, Bologna, Italy
| | - S. Laukontaus
- Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - L. Vikatmaa
- Department of Anesthesiology, Intensive care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - P. Aho
- Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - M. Venermo
- Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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20
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O'Donnell TFX, Carpenter JP, Lane JS, Trani J, Hussain S, Healey C, Malas MB, Schermerhorn ML. Endovascular Aneurysm Sealing is Associated with Higher Medium-Term Survival than Traditional EVAR. Ann Vasc Surg 2020; 63:145-154. [PMID: 31629124 PMCID: PMC7012730 DOI: 10.1016/j.avsg.2019.08.094] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) is the dominant treatment modality for abdominal aortic aneurysm (AAA). Periprocedural risks are low, and cardiovascular events are the principle determinants of long-term survival. Recently, the concept of endovascular aneurysm sealing (EVAS) has been introduced into clinical investigation. In previous cohort studies, EVAS has been associated with a lower all-cause mortality than expected despite device issues. We used a propensity weighted approach to investigate whether EVAS was associated with lower all-cause mortality after aneurysm repair. METHODS We compared 333 patients in the Nellix United States Investigational Device Exemption trial to 15,431 controls from the Vascular Quality Initiative between 2014 and 2016 after applying the exclusion criteria from the investigational device exemption (hemodialysis, creatinine > 2.0 mg/dL, or rupture). We calculated propensity scores and applied inverse probability weighting to compare risk adjusted medium-term survival using Kaplan-Meier and Cox regression. RESULTS After weighting, patients treated with the Nellix EVAS system experienced higher 3-year survival than controls from the Vascular Quality Initiative (93% vs. 88%, respectively). This corresponded to a 41% lower risk of mortality for EVAS compared with EVAR (HR 0.59 [0.38-0.92], P = 0.02). Subgroup analysis demonstrated that the association between EVAS and higher survival was strongest in the subgroup of patients with aneurysms over 5.5 cm (P for interaction < 0.001). In this subgroup, EVAS patients experienced half the rate of mortality as those patients treated with EVAR, with 3-year survival of 92% compared with 86% (HR 0.5 [0.3-0.9], P = 0.02). CONCLUSIONS In this select group of patients, EVAS was associated with higher medium-term survival than traditional EVAR. Although issues with the device have recently surfaced, this exploratory analysis shows that the concept of sac sealing may hold promise. Further study is needed to confirm this finding and determine whether EVAS is associated with lower rates of cardiovascular events.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA; Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Jeffrey P Carpenter
- Division of Vascular Surgery, Cooper Medical School of Rowan University, Camden, NJ
| | - John S Lane
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA; Division of Vascular Surgery, San Diego VA Hospital, San Diego CA
| | - Jose Trani
- Division of Vascular Surgery, Cooper Medical School of Rowan University, Camden, NJ
| | - Sajjad Hussain
- Division of Vascular Surgery, St. Vincent's Hospital, Indianapolis, IN
| | | | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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21
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Cannavale A, Lucatelli P, Corona M, Nardis P, Basilico F, De Rubeis G, Santoni M, Catalano C, Bezzi M. Evolving concepts and management of endoleaks after endovascular aneurysm repair: where do we stand in 2019? Clin Radiol 2019; 75:169-178. [PMID: 31810539 DOI: 10.1016/j.crad.2019.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 10/31/2019] [Indexed: 11/27/2022]
Abstract
In recent years, there has been tremendous progress in endovascular aneurysm repair (EVAR) techniques and devices. This process has seen a change in incidence, risk factors, and treatment of endoleaks as well as in follow-up protocols after EVAR. In particular, recent literature has highlighted new concepts in the evaluation and prevention/treatment of type I and II endoleak after standard EVAR. There is also recent evidence regarding new imaging protocols for follow-up after EVAR, which include magnetic resonance imaging and contrast-enhanced ultrasound. This comprehensive review aims to outline the most recent concepts on imaging follow-up, pathophysiology/risk factors, and management of endoleaks.
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Affiliation(s)
- A Cannavale
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy.
| | - P Lucatelli
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - M Corona
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - P Nardis
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - F Basilico
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - G De Rubeis
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - M Santoni
- Department of Radiological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - C Catalano
- Department of Radiological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - M Bezzi
- Vascular and Interventional Unit, Department of Radiological Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
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22
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Singh AA, Boyle JR. Introduction of New Medical Devices: Lessons Learned From Experience With Endovascular Aneurysm Sealing. J Endovasc Ther 2019; 27:160-162. [PMID: 31694456 DOI: 10.1177/1526602819886338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Aminder A Singh
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
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23
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Endovascular Aneurysm Sealing and Chimney Endovascular Aneurysm Sealing in the Treatment of Type Ia and Type III Endoleaks After Endovascular Aneurysm Repair. Ann Vasc Surg 2019; 61:317-325. [DOI: 10.1016/j.avsg.2019.05.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 11/22/2022]
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24
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Zoethout AC, Zerwes S, Zeebregts CJ, Heyligers JM, De Vries JPJ, Oberhuber A, Karl T, Berg P, Stenson K, Loftus I, Torella F, Szopiński P, Zimmermann E, Holden A, Hyhlik-Duerr A, Reijnen MM. Preliminary outcome of Nellix-in-Nellix extensions in patients treated with failed endovascular aneurysm sealing. J Vasc Surg 2019; 70:1099-1106. [DOI: 10.1016/j.jvs.2019.01.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 01/01/2019] [Indexed: 11/25/2022]
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25
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Mialhe C, Lareyre F, Raffort J. Options to achieve proximal sealing zone during endovascular repair of abdominal aortic aneurysm and correlated classification. Vascular 2019; 27:582-584. [PMID: 31335295 DOI: 10.1177/1708538119864740] [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: 11/17/2022]
Abstract
Since its first development, endovascular aortic aneurysmal repair (EVAR) has largely evolved, and several types of endografts are currently available including bifurcated grafts with supra or infra-renal fixation, fenestrated (FEVAR). Technical advances have led to propose EVAR in patients with challenging anatomy and the indications for using endografts mainly depend on patients’ vascular anatomical characteristics and on the instructions for use. Even if the minimal requirements for standard commercially available endografts have been defined, there is a lack of consensus to help surgeons to choose the most appropriate approach. Here, we propose a four-class abdominal aortic aneurysm (AAA) categorization based on the morphology and the length of the necks considered as landing zones as well as markers of potential evolution of the AAA. This pragmatic classification may help to clarify the decision-making process for selecting the most appropriate endovascular device to treat AAA in accordance with the anatomy and the foreseeable evolution and delayed complication risk to anticipate vascular outcome.
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Affiliation(s)
- Claude Mialhe
- Cardiovascular Surgery Unit, Cardio Thoracic Centre of Monaco, Monaco, France
| | - Fabien Lareyre
- Cardiovascular Surgery Unit, Cardio Thoracic Centre of Monaco, Monaco, France.,University of Côte d'Azur, INSERM, C3M, Nice, France
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26
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Harrison SC, Winterbottom AJ, Coughlin PA, Hayes PD, Boyle JR. Editor's Choice - Mid-term Migration and Device Failure Following Endovascular Aneurysm Sealing with the Nellix Stent Graft System - a Single Centre Experience. Eur J Vasc Endovasc Surg 2019; 56:342-348. [PMID: 30190039 DOI: 10.1016/j.ejvs.2018.06.031] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 06/07/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Endovascular aneurysm sealing (EVAS) with the Nellix stent graft system is a novel concept in the management of abdominal aortic aneurysm (AAA) that aims to reduce the prevalence of all endoleaks following endovascular repair. There are few data describing the longer-term durability of this approach. The aim was to report the longer-term outcomes following EVAS in a single centre. METHODS This is a retrospective review of all patients that underwent Nellix at Cambridge University Hospitals Foundation Trust. Factors that are described as device failure include secondary sac rupture, graft explantation, further surgical procedures for Type 1 endoleak, or major migration of the stent grafts with pressurisation of the aortic sac. RESULTS A total of 161 patients have been treated with Nellix. The indications included primary AAA (n = 115), ruptured AAA (n = 4), salvage of other aortic grafts (n = 18), primary iliac aneurysm (n = 6), and chimney EVAS (ChEVAS) for pararenal AAA (n = 18). In total there have been 42 graft failures in patients treated with EVAS for primary AAA. The 4 year freedom from graft failure was 42% in patients treated for primary AAA. Failures mostly occurred more than 2 years post-Nellix implant. There were eight secondary sac ruptures (incidence 2.4 per 100 person years) and there have been 14 graft explants. CONCLUSIONS Failure of aneurysm sealing following treatment with Nellix has been more common than anticipated and can cause aortic rupture. Post-operative surveillance of Nellix stent grafts is crucial to identify features of failure.
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Affiliation(s)
- Seamus C Harrison
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK.
| | - Andrew J Winterbottom
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
| | - Patrick A Coughlin
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
| | - Paul D Hayes
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
| | - Jonathan R Boyle
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
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27
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Prognostic Nomogram for Patients with Hostile Neck Anatomy after Endovascular Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2019; 56:132-138. [DOI: 10.1016/j.avsg.2018.07.062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/18/2018] [Accepted: 07/19/2018] [Indexed: 12/20/2022]
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28
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Choo XY, Hajibandeh S, Hajibandeh S, Antoniou GA. The Nellix endovascular aneurysm sealing system: current perspectives. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2019; 12:65-79. [PMID: 30858738 PMCID: PMC6385777 DOI: 10.2147/mder.s155300] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background The Nellix endovascular aneurysm sealing (EVAS) system is a novel approach for the treatment of abdominal aortic aneurysm (AAA). We aimed to evaluate the efficacy of EVAS in the management of patients with AAA. Materials and methods We searched PubMed/MEDLINE, CINAHL, and bibliographic reference lists to identify studies reporting clinical outcomes in patients with asymptomatic, non-ruptured AAA treated with EVAS with the Nellix device. We pooled dichotomous outcome data using random-effects models. Results We identified 14 single-arm observational studies, reporting a total of 1,510 patients. The pooled estimate of technical success was 99% (95% CI =98–100; heterogeneity: P=0.869, I2=0%). Adjunctive procedures were carried out in 39% (95% CI =19–63; heterogeneity: P<0.0001, I2=88%). Two cases of aneurysm rupture were reported within 30 days of treatment (0.7%, 95% CI =0.3–1.6; heterogeneity: P=0.923, I2=0%) and another five cases of rupture occurred during follow-up (0.8%, 95% CI =0.4–1.6; heterogeneity: P=0.958, I2=0%). The pooled estimates of early (within 30 days) and late (during follow-up) type I endoleak were 2.8 % (95% CI =1.8–4.2; heterogeneity: P=0.254, I2=18%) and 1.9% (95% CI =1.3–2.8; heterogeneity: P=0.887, I2=0%), respectively. Sac enlargement was noted in 3.1% (95% CI =1.8–5.4; heterogeneity: P=0.419, I2=0%) and device migration in 2.1% (95% CI =0.8–5.3; heterogeneity: P=0.004, I2=65%). The early and late reintervention rates were 2.7% (95% CI =1.7–4.2; heterogeneity: P=0.183, I2=27%) and 3.5% (95% CI =2.3–5.5; heterogeneity: P=0.061, I2=42%), respectively. The pooled estimate of 30-day mortality was 1.5% (95% CI =0.9–2.6; heterogeneity: P=0.559, I2=0%) and the pooled estimate of aneurysm-related death during follow-up was 1.0% (95% CI =0.6–1.9; heterogeneity: P=0.872, I2=0%). Conclusion Reported outcomes of EVAS are acceptable. Type I endoleak, sac enlargement, device migration, and aneurysm rupture are recognized complications. High-level research is required to investigate potential advantages of EVAS over conventional treatments.
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Affiliation(s)
- Xin Y Choo
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK,
| | - Shahab Hajibandeh
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK,
| | - Shahin Hajibandeh
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK,
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK, .,Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
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29
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Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, Dick F, van Herwaarden J, Karkos C, Koelemay M, Kölbel T, Loftus I, Mani K, Melissano G, Powell J, Szeberin Z, ESVS Guidelines Committee, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Kolh P, Lindholt JS, de Vega M, Vermassen F, Document reviewers, Björck M, Cheng S, Dalman R, Davidovic L, Donas K, Earnshaw J, Eckstein HH, Golledge J, Haulon S, Mastracci T, Naylor R, Ricco JB, Verhagen H. Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2019; 57:8-93. [DOI: 10.1016/j.ejvs.2018.09.020] [Citation(s) in RCA: 873] [Impact Index Per Article: 174.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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30
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Yafawi A, McWilliams RG, Fisher RK, England A, Karouki M, Torella F. Stent Frame Movement Following Endovascular Aneurysm Sealing in the Abdominal Aorta. J Endovasc Ther 2018; 26:54-61. [DOI: 10.1177/1526602818814548] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To investigate the incidence and extent of stent frame movement after endovascular aneurysm sealing (EVAS) in the abdominal aorta and its relationships to aneurysm growth and the instructions for use (IFU) of the Nellix endograft. Methods: A retrospective single-center study was conducted to review the clinical data and computed tomography (CT) images of 75 patients (mean age 76±7.6 years; 57 men) who underwent infrarenal EVAS and had a minimum 1-year follow-up. The first postoperative CT scan at 1 month and the subsequent scans were used to measure the distances between the proximal end of the stent frames and a reference visceral vessel using a previously validated technique. Device migration was based on the Society of Vascular Surgery definition of >10-mm downward movement of either Nellix stent frame in the proximal landing zone; a more conservative proximal displacement measure (downward movement ⩾4 mm) was also recorded. Patients were categorized according to adherence to the old (2013) or new (2016) Nellix IFU. Aneurysm diameter was measured for each scan; a change ⩾5 mm was deemed indicative of aneurysm growth. Results: Over a median follow-up of 24 months (range 12–48), proximal displacement ⩾4 mm occurred in 42 (56%) patients and migration >10 mm in 16 (21%), with similar incidences in the right and left stent frames. Proximal displacement was significantly more frequent among patients whose anatomy did not conform to any IFU (p=0.025). Presence of aneurysm growth ⩾5 mm was observed in 14 (19%) patients and was significantly associated with proximal displacement ⩾4 mm (p=0.03). Conclusion: Infrarenal EVAS may be complicated by proximal displacement and migration, particularly when performed outside the IFU. The definition of migration used for endovascular aneurysm repair may be inappropriate for EVAS; a new consensus on definition and measurement technique is necessary.
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Affiliation(s)
- Asma Yafawi
- Institute of Translational Medicine, University of Liverpool, UK
| | - Richard G. McWilliams
- Institute of Translational Medicine, University of Liverpool, UK
- Department of Radiology, Royal Liverpool & Broadgreen University Hospital, Liverpool, UK
- School of Physical Sciences, University of Liverpool, UK
- Liverpool Cardiovascular Institute, Liverpool, UK
| | - Robert K. Fisher
- Liverpool Cardiovascular Institute, Liverpool, UK
- Liverpool Vascular & Endovascular Service, Liverpool, UK
- School of Engineering, University of Liverpool, UK
| | | | - Maria Karouki
- Liverpool Vascular & Endovascular Service, Liverpool, UK
| | - Francesco Torella
- Institute of Translational Medicine, University of Liverpool, UK
- School of Physical Sciences, University of Liverpool, UK
- Liverpool Cardiovascular Institute, Liverpool, UK
- Liverpool Vascular & Endovascular Service, Liverpool, UK
- Institute of Medicine, University of Chester, UK
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31
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van Noort K, Boersen JT, Zoethout AC, Schuurmann RCL, Heyligers JMM, Reijnen MMPJ, Zeebregts CJ, Slump CH, de Vries JPPM. Anatomical Predictors of Endoleaks or Migration After Endovascular Aneurysm Sealing. J Endovasc Ther 2018; 25:719-725. [DOI: 10.1177/1526602818808296] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To identify preoperative anatomical aortic characteristics that predict seal failures after endovascular aneurysm sealing (EVAS) and compare the incidence of events experienced by patients treated within vs outside the instructions for use (IFU). Methods: Of 355 patients treated with the Nellix EndoVascular Aneurysm Sealing System (generation 3SQ+) at 3 high-volume centers from March 2013 to December 2015, 94 patients were excluded, leaving 261 patients (mean age 76±8 years; 229 men) for regression analysis. Of these, 83 (31.8%) suffered one or more of the following events: distal migration ⩾5 mm of one or both stent frames, any endoleak, and/or aneurysm growth >5 mm. Anatomical characteristics were determined on preoperative computed tomography (CT) scans. Patients were divided into 3 groups: treated within the original IFU (n=166), outside the original IFU (n=95), and within the 2016 revised IFU (n=46). Categorical data are presented as the median (interquartile range Q1, Q3). Results: Neck diameter was significantly larger in the any-event cohort vs the control cohort [23.7 mm (21.7, 26.3) vs 23.0 mm (20.9, 25.2) mm, p=0.022]. Neck length was significantly shorter in the any-event cohort [15.0 mm (10.0, 22.5) vs 19.0 mm (10.0, 21.8), p=0.006]. Maximum abdominal aortic aneurysm (AAA) diameter and the ratio between the maximum AAA diameter and lumen diameter in the any-event group were significantly larger than the control group (p=0.041 and p=0.002, respectively). Regression analysis showed aortic neck diameter (p=0.006), neck length (p=0.001), and the diameter ratio (p=0.011) as significant predictors of any event. In the comparison of events to IFU status, 52 (31.3%) of 166 patients in the inside the original IFU group suffered an event compared to 13 (28.3%) of 46 patients inside the 2016 IFU group (p=0.690). Conclusion: Large neck diameter, short aortic neck length, and the ratio between the maximum AAA and lumen diameters are preoperative anatomical predictors of the occurrence of migration (⩾5 mm), any endoleak, and/or aneurysm growth (>5 mm) after EVAS. Even under the refined 2016 IFU, more than a quarter of patients suffered from an event. Improvements in the device seem to be necessary before this technique can be implemented on a large scale in endovascular AAA repair.
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Affiliation(s)
- Kim van Noort
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
- MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Johannes T. Boersen
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
- MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Aleksandra C. Zoethout
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, the Netherlands
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, the Netherlands
| | - Richte C. L. Schuurmann
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
- MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Jan M. M. Heyligers
- Department of Vascular Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | | | - Clark J. Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, the Netherlands
| | - Cornelis H. Slump
- MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Jean-Paul P. M. de Vries
- Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, the Netherlands
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32
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Saitta GM, Gennai S, Munari E, Borsari GT, Lauricella A, Migliari M, Silingardi R. New Conception of Relining in the Endovascular Aneurysm Sealing Era: A Monocentric Case Series Study. Ann Vasc Surg 2018; 56:351.e1-351.e7. [PMID: 30367933 DOI: 10.1016/j.avsg.2018.07.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 07/08/2018] [Accepted: 07/15/2018] [Indexed: 11/17/2022]
Abstract
Over 20 years from the first endovascular aortic repair, endoleaks still represent a common problem, even with newer endograft generation. Numerous procedures can be adopted to manage these complications; relining of the endoprosthesis is a rational technique to treat type III and IV endoleaks. The absence of dedicated materials for these procedures forces the vascular surgeon to perform complex hybrid or endovascular interventions. In this case report, we aimed to evaluate our relining experience using the Nellix device in 5 consecutive cases.
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Affiliation(s)
- Giuseppe M Saitta
- Unit of Vascular Surgery, NOCSAE Nuovo Ospedale Civile di Baggiovara Sant'Agostino Estense, Baggiovara, Modena, Italy
| | - Stefano Gennai
- Unit of Vascular Surgery, NOCSAE Nuovo Ospedale Civile di Baggiovara Sant'Agostino Estense, Baggiovara, Modena, Italy
| | - Elisa Munari
- Unit of Vascular Surgery, NOCSAE Nuovo Ospedale Civile di Baggiovara Sant'Agostino Estense, Baggiovara, Modena, Italy.
| | - Giulia Trevisi Borsari
- Unit of Vascular Surgery, NOCSAE Nuovo Ospedale Civile di Baggiovara Sant'Agostino Estense, Baggiovara, Modena, Italy
| | - Antonio Lauricella
- Unit of Vascular Surgery, NOCSAE Nuovo Ospedale Civile di Baggiovara Sant'Agostino Estense, Baggiovara, Modena, Italy
| | - Mattia Migliari
- Unit of Vascular Surgery, NOCSAE Nuovo Ospedale Civile di Baggiovara Sant'Agostino Estense, Baggiovara, Modena, Italy
| | - Roberto Silingardi
- Unit of Vascular Surgery, NOCSAE Nuovo Ospedale Civile di Baggiovara Sant'Agostino Estense, Baggiovara, Modena, Italy
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33
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Sakalihasan N, Michel JB, Katsargyris A, Kuivaniemi H, Defraigne JO, Nchimi A, Powell JT, Yoshimura K, Hultgren R. Abdominal aortic aneurysms. Nat Rev Dis Primers 2018; 4:34. [PMID: 30337540 DOI: 10.1038/s41572-018-0030-7] [Citation(s) in RCA: 282] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
An abdominal aortic aneurysm (AAA) is a localized dilatation of the infrarenal aorta. AAA is a multifactorial disease, and genetic and environmental factors play a part; smoking, male sex and a positive family history are the most important risk factors, and AAA is most common in men >65 years of age. AAA results from changes in the aortic wall structure, including thinning of the media and adventitia due to the loss of vascular smooth muscle cells and degradation of the extracellular matrix. If the mechanical stress of the blood pressure acting on the wall exceeds the wall strength, the AAA ruptures, causing life-threatening intra-abdominal haemorrhage - the mortality for patients with ruptured AAA is 65-85%. Although AAAs of any size can rupture, the risk of rupture increases with diameter. Intact AAAs are typically asymptomatic, and in settings where screening programmes with ultrasonography are not implemented, most cases are diagnosed incidentally. Modern functional imaging techniques (PET, CT and MRI) may help to assess rupture risk. Elective repair of AAA with open surgery or endovascular aortic repair (EVAR) should be considered to prevent AAA rupture, although the morbidity and mortality associated with both techniques remain non-negligible.
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Affiliation(s)
- Natzi Sakalihasan
- Department of Cardiovascular and Thoracic Surgery, CHU Liège, University of Liège, Liège, Belgium. .,Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium.
| | - Jean-Baptiste Michel
- UMR 1148, INSERM Paris 7, Denis Diderot University, Xavier Bichat Hospital, Paris, France
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Helena Kuivaniemi
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Jean-Olivier Defraigne
- Department of Cardiovascular and Thoracic Surgery, CHU Liège, University of Liège, Liège, Belgium.,Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium
| | - Alain Nchimi
- Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium.,Department of Medical Imaging, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Koichi Yoshimura
- Graduate School of Health and Welfare, Yamaguchi Prefectural University, Yamaguchi, Japan.,Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - 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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34
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Verhoeven EL, Mani K. New Technology Failures: Who to Blame or Time to be Cautious? Eur J Vasc Endovasc Surg 2018; 56:318-319. [DOI: 10.1016/j.ejvs.2018.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022]
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35
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Holden A. Aneurysm Repair with Endovascular Aneurysm Sealing: Technique, Patient Selection, and Management of Complications. Tech Vasc Interv Radiol 2018; 21:181-187. [DOI: 10.1053/j.tvir.2018.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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36
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Gennai S, Saitta GM, Lauricella A, Leone N, Andreoli F, Silingardi R. Endovascular aneurysm sealing with the Nellix endograft in hemodynamically-unstable ruptured abdominal aortic aneurysm with challenging anatomy. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 60:708-717. [PMID: 30160092 DOI: 10.23736/s0021-9509.18.10397-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND To assess immediate and midterm outcomes of hemodynamically-unstable patients with ruptured abdominal aortic aneurysm (rAAA) treated with the Nellix endovascular sealing system (EVAS). METHODS From June 2014 to June 2017, 21 hemodynamically-unstable rAAA patients with challenging anatomies were treated with EVAS. The mean AAA diameter and neck length measured 73±15 mm and 14±10 mm, respectively. All the patients presented an advance trauma life support (ATLS) hemorrhage class ≥1 confirming a compromised hemodynamic status. Primary endpoints include technical success, treatment success, primary safety and 30-day survival. Secondary endpoints include re-intervention rate and time free-from-reintervention. RESULTS Technical success was achieved in 95% (N.=20/21); one patient was converted intraoperatively to open surgery due to ongoing hemorrhage. Seven re-interventions were performed within 30-days and one during the follow-up; treatment success rate of 67% and re-intervention rate of 33%. Early endoleaks were diagnosed in 5 patients (24%). Primary safety was 52%. After a mean follow-up of 11±10 months, survival rates were 81%, 62% and 57% at 1, 6 and 12 months, respectively. Time free-from-reintervention was 15±11 months. CONCLUSIONS Emergency-EVAS (eEVAS) appeared feasible and useful, especially in hemodynamically-unstable patients with challenging anatomies. There are some limitations in this cohort study and larger, prospective and comparative studies are required to confirm eEVAS as part of an emergency treatment protocol for rAAA.
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Affiliation(s)
- Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Giuseppe M Saitta
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Antonio Lauricella
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy -
| | - Francesco Andreoli
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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Garnica Ureña M, Ocaña Guaita J, Aracil Sanus E, Reyes Valdivia A, Gandarias Zúñiga C. Experiencia en nuestro centro con Nellix : EndoVascular Aneurysm Sealing (EVAS) system. Un cambio de paradigma en el tratamiento endovascular del aneurisma aórtico. ANGIOLOGIA 2018. [DOI: 10.1016/j.angio.2017.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Zerwes S, Bruijnen HK, Gosslau Y, Jakob R, Hyhlik-Dürr A. Influence of the Revised Nellix Instructions for Use on Outcomes After Endovascular Aneurysm Sealing. J Endovasc Ther 2018; 25:418-425. [DOI: 10.1177/1526602818781353] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To evaluate the impact of the revised Nellix instructions for use (IFU) from 2016 on clinical outcomes and anatomic applicability by retrospectively applying them to a cohort treated with endovascular aneurysm sealing according to the original IFU 2013. Methods: A single-center study was conducted of 100 consecutive patients (mean age 72±8 years, range 46–91; 89 men) treated electively with standard bilateral EVAS from July 2013 to August 2015 and followed through December 2017. Procedures previously classified within and outside the original IFU from 2013 (75 and 25, respectively) were reclassified according to the revised IFU 2016 (34 and 66, respectively). Stepwise backward logistic regression analysis was performed to evaluate the prognostic value of specific anatomic features for the development of endoleak and/or migration. Results: The single most important morphologic feature disqualifying patients from being within IFU 2016 was a thrombus ratio >1.4 (36 of 41 reclassified patients). Overall technical success was 98% (100% within vs 97% outside IFU 2016, p=0.323) and 30-day mortality was 3% (0% within vs 5% outside IFU 2016, p=0.251). During a median follow-up of 31 months (range 0–53), overall mortality was 21% (15% within vs 24% outside IFU 2016, p=0.469); aneurysm-related mortality was 8% (3% within vs 11% outside IFU 2016, p=0.533). Twenty-six patients developed an endoleak (6 within vs 20 outside IFU 2016, p=0.172) and 23 had migration (4 within vs 19 outside IFU 2016, p=0.088). Both proximal neck length <10 mm and neck angulation >60° were positive predictors for the development of endoleak and/or migration. A reintervention was performed in 26 patients (7 within vs 19 outside IFU 2016, p=0.376). While a significant difference was found between the within vs outside IFU 2016 groups with regard to freedom from migration (p=0.026) and the composite freedom from endoleak and/or migration (p=0.021), there were no significant differences in survival (p=0.201) or freedom from reintervention (p=0.505), suggesting a limited effectiveness of the new IFU 2016. Conclusion: The IFU 2016 reduced the anatomic applicability to 34% from 75% for the original IFU 2013. The lack of significant intergroup differences in terms of survival and reinterventions suggests a limited effectiveness of the new IFU 2016.
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Affiliation(s)
- Sebastian Zerwes
- Department of Vascular and Endovascular Surgery, Klinikum Augsburg, Germany
| | - Hans-Kees Bruijnen
- Department of Vascular and Endovascular Surgery, Klinikum Augsburg, Germany
| | - Yvonne Gosslau
- Department of Vascular and Endovascular Surgery, Klinikum Augsburg, Germany
| | - Rudolf Jakob
- Department of Vascular and Endovascular Surgery, Klinikum Augsburg, Germany
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van Noort K, Overeem SP, van Veen R, Heyligers JMM, Reijnen MMPJ, Schuurmann RCL, Slump CH, Kropman R, de Vries JPPM. Apposition and Positioning of the Nellix EndoVascular Aneurysm Sealing System in the Infrarenal Aortic Neck. J Endovasc Ther 2018; 25:428-434. [PMID: 29785859 DOI: 10.1177/1526602818777494] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To investigate the initial proximal position and seal of the Nellix EndoVascular Aneurysm Sealing (EVAS) system in the aortic neck using a novel methodology. METHODS Forty-six consecutive patients who underwent elective EVAS for an abdominal aortic aneurysm were retrospectively selected and dichotomized into an early (n=23) and a late (n=23) group. The aortic neck morphology and aortic neck surface (ANS) were determined on preoperative computed tomography (CT) scans; the endograft position and nonapposition surface (NAS) were determined on the 1-month CT scans. The position of the proximal endobag boundary was measured by 2 experienced observers to analyze the interobserver variability for the EVAS NAS measurements. The shortest distance from the lowest renal artery to the endobag (shortest fabric distance) and the shortest distance from the endobag to the end of the infrarenal neck (shortest sealing distance) were determined. The intraclass correlation coefficients (ICCs) are presented with the 95% confidence interval (CI). Continuous data are presented as the median and interquartile range (IQR: Q3 - Q1). RESULTS There were no differences between the early and late EVAS groups regarding aortic neck morphology except for the neck calcification circumference [41° (IQR 33°) vs 87° (IQR 60°), respectively; p=0.043]. Perfect agreement was observed for the NAS (ICC 0.897, 95% CI 0.780 to 0.956). The NAS as a percentage of the preoperative ANS was 47% (IQR 43) vs 49% (IQR 49) for the early vs late groups, respectively (p=0.214). The shortest fabric distances were 5 mm (IQR 5) and 4 mm (IQR 7) for the early and late groups, respectively (p=0.604); the shortest sealing distances were 9 mm (IQR 13) and 16 mm (IQR 17), respectively (p=0.066). CONCLUSION Accurate positioning of the Nellix EVAS system in the aortic neck may be challenging. Despite considerable experience with the system, still around half of the potential seal in the aortic neck was missed in the current series, without improvement over time. This should be considered during preoperative planning and may be a cause of a higher than expected complication rate. Detailed post-EVAS nonapposition surface can be determined with the described novel methodology that takes into account the sometimes irregularly shaped top of the sealing endobags.
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Affiliation(s)
- Kim van Noort
- 1 Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands.,2 MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, the Netherlands
| | - Simon P Overeem
- 1 Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands.,2 MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, the Netherlands
| | - Ruben van Veen
- 1 Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands.,2 MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, the Netherlands
| | - Jan M M Heyligers
- 3 Department of Vascular Surgery, Elisabeth TweeSteden Hospital, Tilburg, the Netherlands
| | | | - Richte C L Schuurmann
- 1 Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands.,2 MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, the Netherlands
| | - Cornelis H Slump
- 2 MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, the Netherlands
| | - Rogier Kropman
- 1 Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
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Initial Clinical Experience Using the Low-Profile Altura Endograft System With Double D-Shaped Proximal Stents for Endovascular Aneurysm Repair. J Endovasc Ther 2018; 25:379-386. [DOI: 10.1177/1526602818771973] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To report the initial clinical results of endovascular aneurysm repair (EVAR) using the low-profile (14-F) Altura Endograft System, which features a double “D-shaped” stent design with suprarenal fixation and modular iliac components that are deployed from distal to proximal. Methods: From 2011 to 2015, 90 patients (mean age 72.8±8.3 years; 79 men) with abdominal aortic aneurysm (AAA; mean diameter 53.8±5.7 mm) were treated at 10 clinical sites in 2 prospective, controlled clinical studies using the Altura endograft. Outcomes evaluated included mortality, major adverse events (MAEs: all-cause death, stroke, paraplegia, myocardial infarction, respiratory failure, bowel ischemia, and blood loss ≥1000 mL), and clinical success (freedom from procedure-related death, type I/III endoleak, migration, thrombosis, and reintervention). Results: Endografts were successfully implanted in 89 (99%) patients; the single failure was due to delivery system malfunction before insertion in the early-generation device. One (1%) patient died and 4 patients underwent reinterventions (1 type I endoleak, 2 iliac limb stenoses, and 1 endograft occlusion) within the first 30 days. During a median follow-up of 12.5 months (range 11.5–50.9), there were no aneurysm ruptures, surgical conversions, or AAA-related deaths. The cumulative MAE rates were 3% (3/89) at 6 months and 7% (6/89) at 1 year. Two patients underwent coil embolization of type II endoleaks at 6.5 months and 2.2 years, respectively. Clinical success was 94% (84/89) at 30 days, 98% (85/87) at 6 months, and 99% (82/83) at 1 year. Conclusion: Early results suggest that properly selected AAA patients can be safely treated using the Altura Endograft System with favorable midterm outcome. Thus, further clinical investigation is warranted to evaluate the role of this device in the treatment of AAA.
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Torella F, McWilliams RG, Fisher RK. Commentary: Endovascular Sealing of Abdominal Aortic Aneurysms: Do Current Data Justify Wider Use? J Endovasc Ther 2018; 25:282-283. [PMID: 29642736 DOI: 10.1177/1526602818767627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Francesco Torella
- 1 Liverpool Vascular & Endovascular Service, University of Liverpool, UK.,2 Institute of Translational Medicine, University of Liverpool, UK.,3 School of Physical Sciences, University of Liverpool, UK.,4 Liverpool Cardiovascular Institute, Liverpool, UK.,5 Institute of Medicine, University of Chester, UK
| | - Richard G McWilliams
- 1 Liverpool Vascular & Endovascular Service, University of Liverpool, UK.,4 Liverpool Cardiovascular Institute, Liverpool, UK.,6 Department of Radiology, Royal Liverpool & Broadgreen University Hospital, Liverpool, UK
| | - Robert K Fisher
- 1 Liverpool Vascular & Endovascular Service, University of Liverpool, UK.,4 Liverpool Cardiovascular Institute, Liverpool, UK.,7 School of Engineering, University of Liverpool, UK
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Peters AS, Hatzl J, Bischoff MS, Böckler D. Comparison of endovascular aneurysm sealing and repair with respect to contrast use and radiation in comparable patient cohorts. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 61:67-72. [PMID: 29616520 DOI: 10.23736/s0021-9509.18.10206-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Due to recent advances in endograft design and percutaneous access, technical success could be increased during endovascular aneurysm repair (EVAR). Beside EVAR, endovascular aneurysm sealing (EVAS) provides an alternative procedure to treat aneurysms. To compare the two methods, additional benchmark criteria should be evaluated: Screening time, dose area product (DAP), procedure time and contrast use. In this study these technical variables are analyzed for EVAS vs. EVAR in comparable patient cohorts. METHODS It is a retrospective, single-center study. Only elective cases of infrarenal aortic aneurysms were included, all treated by the same surgeon (D.B.). Procedures were performed within the instructions for use without additional procedures. All operations were undertaken in a hybrid operating theatre. For EVAR, only the Medtronic Endurant® and the Gore C3 Excluder® were included. For EVAS the Nellix® from Endologix was used. RESULTS Between 2012 and 2016, 67 patients were treated with EVAS and 40 with EVAR; of these 20 and 16 could be introduced into the study respectively. Median age was 73 and 72 years respectively (only men). The two groups were comparable in terms of BMI, GFR and ASA-status. Screening time was reduced for EVAS (10.6 vs. 14.5 min., P<0.01), while the DAP was not significantly different. Procedural time and contrast use were increased for EVAS (120 vs. 96 min., 120 vs. 79 mL, P<0.01). CONCLUSIONS Especially the younger EVAS-procedure requires ongoing review in order to further reduce contrast agent. Reduced screening time for EVAS does not have a significant impact on radiation dose.
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Affiliation(s)
- Andreas S Peters
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Johannes Hatzl
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Moritz S Bischoff
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany -
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Ockert S, Heinrich M, Kaufmann T, Syburra T, Lopez R, Seelos R. Endovascular aortic sealing with Nellix reduces intraoperative radiation dose when compared to endovascular aortic repair. J Vasc Surg 2018; 67:1068-1073. [DOI: 10.1016/j.jvs.2017.07.126] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 07/20/2017] [Indexed: 10/18/2022]
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Zoethout AC, Boersen JT, Heyligers JMM, de Vries JPPM, Zeebregts CJAM, Reijnen MMPJ. Two-Year Outcomes of the Nellix EndoVascular Aneurysm Sealing System for Treatment of Abdominal Aortic Aneurysms. J Endovasc Ther 2018; 25:270-281. [PMID: 29591724 PMCID: PMC5967009 DOI: 10.1177/1526602818766864] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Purpose: To analyze the 2-year outcomes of endovascular aneurysm sealing (EVAS) according to 2 versions of the instructions for use (IFU). Methods: A retrospective study was conducted involving 355 consecutive patients treated with the first-generation EVAS device from April 2013 to December 31, 2015, at 3 high-volume centers. Out of 355 patients treated with EVAS, 264 were elective asymptomatic infrarenal EVAS procedures suitable for analysis. In this cohort, 168 (63.3%) patients were treated within the IFU 2013 criteria; of these 48 (18.2%) were in compliance with the revised IFU 2016 version. Results: Overall technical success was 98.2% (165/168) in the IFU 2013 group and 97.9% (47/48) in the IFU 2016 subgroup (p=0.428). The 2-year freedom from reintervention estimates were 89.7% (IFU 2013) and 95.7% (IFU 2016), with significantly more reinterventions in the first 45 cases (p=0.005). The stenosis/occlusion estimates were 6.5% (IFU 2013) and 4.2% (IFU 2016; p=0.705). Nine (5.4%) endoleaks (8 type Ia and 1 type Ib) were observed within the IFU 2013 cohort; 3 (2.1%) were in the IFU 2016 subgroup (p=0.583). Migration ≥10 mm or ≥5 mm requiring intervention was reported in 12 (7.1%) patients in the IFU 2013 cohort but none within the IFU 2016 subgroup. Ten (6.0%) patients demonstrated aneurysm growth in the IFU 2013 cohort, of which 2 (4.2%) were in the IFU 2016 subgroup. Overall survival and freedom from aneurysm-related death estimates at 2 years were 90.9% and 97.6% in the IFU 2013 cohort (IFU 2016: 95.5% and 100.0%). The prevalence of complications seemed lower within IFU 2016 without significant differences. Conclusion: This study shows acceptable 2-year results of EVAS used within the IFU, without significant differences between the 2 IFU versions, though longer follow-up is indicated. The refined IFU significantly reduced the applicability of the technique.
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Affiliation(s)
- Aleksandra C Zoethout
- 1 Department of Vascular Surgery, Rijnstate Hospital, Arnhem, the Netherlands.,2 Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Johannes T Boersen
- 1 Department of Vascular Surgery, Rijnstate Hospital, Arnhem, the Netherlands.,3 Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Jan M M Heyligers
- 4 Department of Vascular Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | | | - Clark J A M Zeebregts
- 2 Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
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Tripathi RK. Commentary: Imaging of Endograft Apposition, Position, and Expansion in the Aortic Neck Following EVAR: Evaluation of a Novel Concept to Predict Type Ia Endoleak. J Endovasc Ther 2018; 25:376-378. [PMID: 29575991 DOI: 10.1177/1526602818764741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Ramesh K Tripathi
- 1 Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, Maroochydore DC, Queensland, Australia
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46
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Tasleem S, Badri H, Ranjeet N, Antoniou GA. Endobag separation - an ominous sign after endovascular aneurysm sealing with the Nellix device. VASA 2018; 47:327-329. [PMID: 29575981 DOI: 10.1024/0301-1526/a000699] [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: 11/19/2022]
Abstract
Our report aims to alert physicians performing endovascular aneurysm sealing with the Nellix endoprosthesis to the risk of rupture when endobag separation is noticed on computed tomography. Endobag separation when observed with acute presentation of abdominal pain is an indicator of imminent rupture and prompt interventional treatment should be undertaken.
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Affiliation(s)
- Sadia Tasleem
- 1 Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, United Kingdom
| | - Hassan Badri
- 1 Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, United Kingdom
| | - Narlawar Ranjeet
- 2 Department of Radiology, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, United Kingdom
| | - George A Antoniou
- 1 Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, United Kingdom
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Martinelli O, Fresilli M, Irace L, Venosi S, Jabbour J, Picone V, Maruca D, Di Girolamo A, Gossetti B. An Alternative Approach for Treating a Type Ia Endoleak after Conventional EVAR Using the Nellix Endovascular Aneurysm Sealing. Ann Vasc Surg 2018; 49:316.e5-316.e10. [PMID: 29501907 DOI: 10.1016/j.avsg.2017.12.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 12/03/2017] [Accepted: 12/13/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND To report the use of a Nellix endovascular aneurysm sealing (EVAS) device, to successfully treat a type Ia endoleak (EL) after an endovascular aortic repair (EVAR). CASE REPORT A 70-year-old man was diagnosed with a 90-mm aortic aneurysm, suspicious for being inflammatory. It was initially treated successfully, with a Medtronic Endurant (Medtronic, Minneapolis, MN, USA). Five years after the index endovascular repair, an asymptomatic type Ia EL was detected on duplex ultrasound and computed tomographic angiogram. Other endovascular solutions in the form of proximal cuff, chimney was considered difficult to execute due to challenges in planning, manipulation, and renal cannulation caused by the short proximal sealing zone above the existing stent graft and the constraints of the previous endograft. Thus, a relining of the previous endoprothesis was performed using the Nellix system (Endologix, Inc., Irvine, CA, USA). One-year follow-up imaging demonstrated successful resolution of the EL and persistent sealing of the Nellix device. CONCLUSIONS Nellix EVAS system can be an alternative and safe option for relining a stent graft with a type Ia EL. Nellix platform can be added to the clinician's armamentarium for treating type Ia EL after conventional EVAR of infrarenal abdominal aortic aneurysm (AAA).
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Affiliation(s)
- Ombretta Martinelli
- Department of Vascular and Endovascolar Surgery, Policlinico "Umberto I" Hospital, Rome, Italy
| | - Mauro Fresilli
- Department of Vascular and Endovascolar Surgery, Policlinico "Umberto I" Hospital, Rome, Italy.
| | - Luigi Irace
- Department of Vascular and Endovascolar Surgery, Policlinico "Umberto I" Hospital, Rome, Italy
| | - Salvatore Venosi
- Department of Vascular and Endovascolar Surgery, Policlinico "Umberto I" Hospital, Rome, Italy
| | - Jihad Jabbour
- Department of Vascular and Endovascolar Surgery, Policlinico "Umberto I" Hospital, Rome, Italy
| | - Veronica Picone
- Department of Vascular and Endovascolar Surgery, Policlinico "Umberto I" Hospital, Rome, Italy
| | - Debora Maruca
- Department of Vascular and Endovascolar Surgery, Policlinico "Umberto I" Hospital, Rome, Italy
| | - Alessia Di Girolamo
- Department of Vascular and Endovascolar Surgery, Policlinico "Umberto I" Hospital, Rome, Italy
| | - Bruno Gossetti
- Department of Vascular and Endovascolar Surgery, Policlinico "Umberto I" Hospital, Rome, Italy
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Zerwes S, Hyhlik-Dürr A. Commentary: Polymerization and Its Similarity With Building Solid Evidence. J Endovasc Ther 2018; 25:207-208. [DOI: 10.1177/1526602818755903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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49
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Reijnen MMPJ, Holden A. Status of Endovascular Aneurysm Sealing After 5 Years of Commercial Use. J Endovasc Ther 2018; 25:201-206. [DOI: 10.1177/1526602818755484] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Andrew Holden
- Department of Interventional Radiology, Auckland Hospital, Auckland, New Zealand
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Abstract
Endovascular sealing is a new technique for the repair of abdominal aortic aneurysms. Commercially available in Europe since 2013, it takes a revolutionary approach to aneurysm repair through minimally invasive techniques. Although aneurysm sealing may be thought as more stable than conventional endovascular stent graft repairs, post-implantation movement of the endoprosthesis has been described, potentially leading to late complications. The paper presents for the first time a model, which explains the nature of forces, in static and dynamic regimes, acting on sealed abdominal aortic aneurysms, with references to real case studies. It is shown that elastic deformation of the aorta and of the endoprosthesis induced by static forces and vibrations during daily activities can potentially promote undesired movements of the endovascular sealing structure.
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