Multicenter Experience With Large Diameter Balloon-Expandable Stent-Grafts for the Treatment of Infrarenal Penetrating Aortic Ulcers

Abdominal Penetrating Aortic Ulcer and Endovascular Treatments: A Systematic Review and Meta-Analysis

BACKGROUND

Abdominal penetrating aortic ulcer (aPAU) is defined as an ulceration of the aortic intima and media lamina, even with rupture of the internal elastic lamina. Recently, there have been an increasing number of publications on endovascular treatment for aPAU. This review aimed to assess the efficacy and safety of endovascular treatment and provide clinicians with the latest evidence-based medical data.

METHODS

3 academic databases (Embase, PubMed, and Scopus) were systematically searched for literature reporting on aPAU from 1986 (the earliest appearance of the concept of aPAU) to September 1, 2021, and related data were collected and evaluated. A fixed/random effects model was used to construct the forest plots. Funnel plots and linear regression tests were used to assess the publication bias.

RESULTS

6 articles including 121 patients were included in the analysis. The average age was 71.4 years, with 72.7% of males and 85.6% with hypertension. Saccular aneurysms (SA) were the most prevalent complication (35.5%). Endovascular treatment had a perioperative mortality rate of .24% (95% CI, .00-2.70). The technical success rate was 99.15% (95% CI, 96.49-100). The type-II endoleak rate was 5.69% (95% CI, .00-12.13). The 1-year survival rate was 95.69% (95% CI, 90.49-100). The revascularization rate was 7.20% (95% CI, .07-14.32). Endovascular treatments for aPAU would lead to a high rate of technical success, few complications, and satisfactory 1-year survival.

CONCLUSIONS

aPAU are a common disease that mainly affects elderly males with hypertension and hyperlipidemia. Endovascular treatment is required when an ulcer progresses rapidly or manifests symptoms. Endovascular treatment is associated with high technical success, low complication, and satisfactory 1-year survival. Further investigation into the long-term results of endovascular treatment is necessary.

Systematic Review on Abdominal Penetrating Atherosclerotic Aortic Ulcers: Outcomes of Endovascular Repair

PURPOSE

To systematically review existing evidence on outcomes of endovascular repair of abdominal atherosclerotic penetrating aortic ulcers (PAUs).

MATERIAL AND METHODS

Cochrane Central Registry of Registered Trials (CENTRAL), MEDLINE (via PubMed), and Web of Science databases were systematically searched. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol (PRISMA-P 2020). The protocol was registered in the international registry of systematic reviews (PROSPERO CRD42022313404). Studies reporting on technical and clinical outcomes of endovascular PAU repair in 3 or more patients were included. Random effects modeling was used to estimate pooled technical success, survival, reinterventions, and type 1 and type 3 endoleaks. Statistical heterogeneity was assessed using the I² statistic. Pooled results are reported with 95% confidence intervals (CIs). Study quality was assessed using an adapted version of the Modified Coleman Methodology Score.

RESULTS

Sixteen studies including 165 patients with a mean/median age ranging from 64 to 78 years receiving endovascular therapy for PAU between 1997 and 2020 were identified. Pooled technical success was 99.0% (CI: 96.0%-100%). In all, 30-day mortality was 1.0% (CI: 0%-6.0%) with an in-hospital mortality of 1.0% (CI: 0.0%-13.0%). There were no reinterventions, type 1, or type 3 endoleaks at 30 days. Median/mean follow-up ranged from 1 to 33 months. Overall, there were 16 deaths (9.7%), 5 reinterventions (3.3%), 3 type 1 (1.8%), and 1 type 3 endoleak (0.6%) during follow-up. The quality of studies was rated low according to the Modified Coleman score at 43.4 (+/- 8.5) of 85 points.

CONCLUSION

There is low-level evidence on outcomes of endovascular PAU repair. While in the short-term endovascular repair of abdominal PAU seems safe and effective, mid-term and long-term data are lacking. Recommendations with regard to treatment indications and techniques in asymptomatic PAU should be made cautiously.

CLINICAL IMPACT

This systematic review demonstrated that evidence on outcomes of endovascular abdominal PAU repair is limited. While in the short-term endovascular repair of abdominal PAU seems safe and effective, mid-term and long-term data are lacking. In the context of a benign prognosis of asymptomatic PAU and lacking standardization in current reporting, recommendations with regard to treatment indications and techniques in asymptomatic PAUs should be made cautiously.

Midterm results of complicated penetrating abdominal aortic ulcer treated by aortobi-iliac endograft and embolization

BACKGROUND

Penetrating aortic ulcer (PAU) is determined by atherosclerotic degeneration of the tunica media with disruption of the intima. Usually it is detected in the thoracic aorta, with few series describing an abdominal location. The aim of the study was to report early and late outcomes of the endovascular repair of complicated infrarenal abdominal PAU (a-PAU) by aortobi-iliac endograft and embolization.

METHODS

Data from all complicated a-PAU submitted to endovascular repair by aortobi-iliac endograft (Cook-Zenith Alpha) between 2016 and 2021 (February) were analyzed. The a-PAU coil embolization was performed to decrease the risk of persistent type II endoleak whenever possible. Complicated a-PAU were defined according with the presence of symptoms, aortic rupture, or saccular or pseudo-aneurysm. Technical success, 30-day morbidity and mortality, and reinterventions were assessed as early outcomes. Survival, endoleaks, and freedom from reinterventions were evaluated during follow-up.

RESULTS

Of 1153 endovascular aortic procedures, 45 cases (4%) of complicated a-PAU were identified. Fourteen cases (31%) were managed in urgent setting (symptoms, n = 10 [22%]; shock, n = 4 [9%]). The median diameter of a-PAU was 49 mm (interquartile range, 14 mm). Thirteen patients (29%) had severe femoral or iliac access (angle >90°, circumferential calcification [>50%], hemodynamic iliac stenosis or obstruction, an external iliac artery diameter of less than 7 mm, or a previous femoral surgical graft). The a-PAU embolization was performed in 30 cases (67%). Technical success was achieved in all patients. Postoperative cardiac, pulmonary and renal morbidity occurred in one (2%), two (4%), and eight (18%) patients, respectively. Two patients (4%) required reintervention within 30 days for access related complications. The 30-day mortality was 2%. At a median follow-up of 24 months (interquartile range, 18 months), no type I or III endoleaks, iliac leg occlusion, or graft infection occurred and no patient required late reinterventions; the 36-month survival rate was 72%. No a-PAU enlarged or ruptured during follow-up.

CONCLUSIONS

Endovascular repair of complicated a-PAU by a low-profile aortobi-iliac endograft and embolization is safe and effective. Excellent technical results are reported even in challenging anatomic features. Midterm clinical results are satisfactory in terms of aortic-related complications or mortality, freedom from reintervention, and survival.

Endovascular Aneurysm Repair With AFX Stent-Grafts or Tube Grafts for Sacciform Infrarenal Pathologies in a Narrow Aortic Anatomy

PURPOSE

The objective of this study was to compare the outcomes of patients treated with tube grafts and AFX stent-graft in the narrow infrarenal aortic anatomy.

MATERIALS AND METHODS

Patients with penetrating aortic ulcers (PAUs) or sacciform aneurysms of the infrarenal aorta and an aortic bifurcation diameter ≤20 mm who underwent endovascular aneurysm repair (EVAR) with bifurcated AFX or tube stent-grafts (TUBE) between 2012 and 2020 were included. Demographic data and the outcome of the AFX group were compared with the TUBE group. All morphological measurements in the preoperative and postoperative computed tomography scans were performed in the aortic centerline.

RESULTS

Fifty-one patients (female: 12/51; 29%; median age: 72 years [63, 77]) with a median follow-up of 10 (3, 39) months, were included, of whom 35/51 (69%) had PAUs and 11/51 were symptomatic (22%). The aortic bifurcation diameter was 17 mm (15, 18) with severe calcifications in 25/51 (49%). The distal aortic landing zone was longer in the TUBE group (9 mm vs 24 mm; p<0.001). The technical success was 96% with a median aneurysm shrinkage of 8% (3, 13), which was comparable between the groups (p=0.264). Periprocedural mortality, conversion to open surgery, myocardial infarction, and stroke were not observed. Two type Ia endoleaks (EL) and 2 type Ib EL occurred, all in the TUBE group (Type 1 EL; 19 vs 0%; p=0.013). The limb patency in the AFX group was 100%. One patient with a tube graft developed an infrarenal aortic thrombosis 40 months after the intervention. The reintervention rate in the TUBE group was higher (14 vs 0%; p=0.032) and included 3 aortic cuff implantations and 1 covered endovascular aortic reconstruction of aortic bifurcation (CERAB).

CONCLUSION

AFX stent-graft showed a lower rate of type I endoleaks and reinterventions in sacciform infrarenal aortic pathologies during the early and midterm follow-up.