Barriers to Endovascular Aortic Aneurysm Repair: Past Experience and Implications for Future Device Development

Editor's Choice - Endurant Stent Graft in Patients with Challenging Neck Anatomy "One Step Outside Instructions for Use": Early and Midterm Results from the EAGLE Registry

OBJECTIVE

The aim of the Endurant for Challenging Anatomy: Global Experience (EAGLE) registry is to evaluate prospectively the technical and clinical success rate of a stentgraft used in patients with challenging neck anatomy outside the instructions for use (IFU) but within objective anatomical limits.

METHODS

This was a prospective, international, multicentre, observational study. From 1 February 2012 to 1 September 2017, patients with an abdominal aortic aneurysm with a challenging infrarenal neck that were deemed suitable for endovascular aneurysm repair were included prospectively at 23 European centres. Patients were distributed by anatomy into three groups: short neck (SN; infrarenal neck 5 - 10 mm in combination with suprarenal angulation [α] ≤ 45° and infrarenal angulation [β] ≤ 60°); medium neck (MN; infrarenal neck 10 - 15 mm with α ≤ 60° and β 60° - 75° or α 45°- 60° and β ≤ 75°; and long angulated neck (LN; infrarenal neck ≥ 15 mm with α ≤ 75° and β 75°- 90° or α 60°- 75° and β ≤ 90°. All computed tomography scans were reviewed by an independent core laboratory. Primary outcomes were technical and clinical success. Secondary endpoints were peri-operative major adverse events, all cause mortality, aneurysm related mortality, endoleaks, migration, and secondary intervention.

RESULTS

One hundred and fifty patients (81.3% male) were included (SN = 55, MN = 16, LN = 79). The median follow up was 36 ± 12.6 months. In the overall cohort, the technical success rate was 93.3%. Estimated freedom from aneurysm related death was 97.3% at three years. Freedom from secondary interventions was 84.7% at three years. Estimated clinical success was 96.0%, 90.8%, and 83.2% at 30 days, one year, and three years, respectively. Estimated freedom from all cause mortality, late type IA endoleak, and migration at three years was 75.1%, 93.7%, and 99.3%, respectively.

CONCLUSION

The early and midterm results of the EAGLE registry show that endovascular repair with the Endurant stentgraft in selected patients with challenging infrarenal neck anatomy yields results in line with large "real world" registries. Long term results are awaited for more definitive conclusions.

Anatomic eligibility for endovascular aneurysm repair preserved over 2 years of surveillance

OBJECTIVE

Endovascular aneurysm repair (EVAR) is a widely used option for patients with suitable vascular anatomy who have a large infrarenal abdominal aortic aneurysm (AAA). Patients with small AAAs are managed with careful surveillance and it is a common concern that their anatomy may change with AAA growth, and their option for EVAR may become limited. Device innovation has resulted in expanded ranges of anatomy that may be eligible for EVAR. This study sought to identify changes in anatomic eligibility for repair with contemporary endovascular devices in AAA patients, monitored by computed tomography scan over the course of 2 years.

METHODS

Patients from the Non-Invasive Treatment of Abdominal Aortic Aneurysm Clinical Trial (N-TA³CT, NCT01756833) were included in this analysis. Females had baseline AAA maximum transverse diameter between 3.5 and 4.5 cm, and males had baseline maximum transverse diameter between 3.5 and 5.0 cm. Patients were included in this analysis if they completed pre-enrollment and 2-year follow-up computed tomography imaging. Pertinent anatomic measurements were performed on a postprocessing workstation in a centralized imaging core laboratory. EVAR candidacy was determined by measuring proximal aortic neck diameter, AAA length, and infrarenal neck angulation. Patients were considered to be eligible for EVAR if they qualified for at least one of the seven studied devices' instructions for use at baseline and at 2 years. A paired t test analysis was used to detect differences in aortic measurements over 2 years, and the McNemar test was used to compare eligibility over 2 years.

RESULTS

We included 192 patients in this analysis-168 male and 24 female. Of these patients, 85% were eligible for EVAR at baseline and 85% after 2 years of follow-up (P = 1.00; 95% confidence interval -0.034 to 0.034). Of the 164 EVAR candidates at baseline, 160 (98%) remained eligible over 2 years of surveillance. Insufficient neck length was the most common reason for both ineligibility at baseline (18 of 28 patients) as well as loss of candidacy over 2 years (3 of 4 patients).

CONCLUSIONS

The majority of patients eligible for EVAR when entering a surveillance program for small AAA remain eligible after 2 years. Substantial changes in AAA neck anatomy resulting in loss of EVAR treatment options are infrequent. Patients with anatomic AAA progression beyond EVAR eligibility remain candidates for complex EVAR and open repair.

The Polymer-Based Technology in the Endovascular Treatment of Abdominal Aortic Aneurysms

An abdominal aortic aneurysm (AAA) is a dilatation of the abdominal aorta that progressively grows until it ruptures. Treatment is typically recommended when the diameter is more than 5 cm. The EVAR (Endovascular aneurysm repair) is a minimally invasive procedure that involves the placement of an expandable stent graft within the aorta to treat aortic disease without operating directly on the aorta. For years, stent grafts' essential design was based on metallic stent frames to support the fabric. More recently, a polymer-based technology has been proposed as an alternative method to seal AAA. This review underlines the two platforms that are based on a polymer technology: (1) the polymer-filled endobags, also known as Endovascular Aneurysm Sealing (EVAS) with Nellix stent graft; and (2) the O-ring EVAR polymer-based proximal neck sealing device, also known as an Ovation stent graft. Polymer characteristics for this particular aim, clinical applications, and durability results are hereby summarized and commented critically. The technique of inflating endobags filled with polymer to exclude the aneurysmal sac was not successful due to the lack of an adequate proximal fixation. The platform that used polymer to create a circumferential sealing of the aneurysmal neck has proven safe and effective.

Endovascular aortic repair in patients with challenging anatomies: the EXTREME study

AIMS

The aim of this study was to report the 30-day technical and clinical success with endovascular repair using the ultra-low-profile Ovation stent graft in patients judged to be outside the instructions for use (IFU) for conventional endografts, while amenable to treatment within the IFU for Ovation.

METHODS AND RESULTS

One hundred and twenty-two patients (78.65±7.67 years; 111 male) were enrolled. Patients were evaluated as being outside the IFU for standard endografts because of the absence of a suitable proximal aortic neck in 109 cases (89.3%), of inadequate access vessels in 13 (10.7%), or both in 111 (90.9%). Mean aneurysm (abdominal aortic aneurysm [AAA]) diameter was 52.96±10.1 mm; mean aortic neck length was 7.75±6.05 mm. Technical success (98.4%) was achieved in all but two patients due to a type Ia endoleak. At completion angiography, 15 (12.3%) patients presented a type II endoleak. All patients underwent 30-day follow-up. Primary clinical success at one month was 96.8%, assisted clinical success 98.4%. There were no type I endoleaks, while 12 (9.8%) type II endoleaks were still evident, in the absence of sac expansions. Two patients (1.6%) presented an asymptomatic limb occlusion.

CONCLUSIONS

Our experience suggests that, in a selected population of patients with challenging anatomy outside the IFU for conventional endografts, endovascular aneurysm repair (EVAR) using the Ovation stent graft can be performed safely with satisfactory immediate outcomes.

LUCY results show females have equivalent outcomes to males following endovascular abdominal aortic aneurysm repair despite more complex aortic morphology

OBJECTIVE

Females remain underrepresented in studies of endovascular aneurysm repair (EVAR) owing to anatomic ineligibility for EVAR devices. The aim of the LUCY study is to explore the comparative safety and effectiveness of EVAR using a low-profile stent graft (Ovation; Endologix, Inc, Irvine, Calif) in females as well as males.

METHODS

The LUCY registry was a prospective, nonrandomized, multicenter study where patient enrollment was stratified by sex in a two-to-one ratio (male-to-female). Main outcomes were procedural data, 30-day major adverse events, device-related adverse events confirmed with contrast-enhanced computed tomography scans, secondary interventions, and hospital readmissions. Adverse events were adjudicated by a clinical events committee. Patients were followed at their 1-month and 1-year follow-up visits.

RESULTS

A total of 225 patients (76 females, 149 males) were enrolled at 39 U.S. centers. No statistically significant sex differences were observed in demographics or medical history. Females presented with smaller access vessels (6.2 vs 7.7 mm; P < .001), statistically smaller neck diameter (22 mm vs 23 mm; P = .001), similar neck angulation (11% vs 9% angulation >45°; P = .81), and smaller maximum abdominal aortic aneurysm (AAA) diameter (50 mm vs 53 mm; P = .01), however, these factors do not seem to be clinically significant. Technical success was 99%, and the median hospital stay was 1 day. The incidence of MAE through 30 days was 1.3% in females and 2.0% in males. There were no differences between sexes observed among the 30-day perioperative outcomes. The 30-day secondary intervention rate was 0.4%. The all-cause readmission rate through 30 days was 5.3% in females and 6.7% in males. There were no reports of limb occlusion or deaths within the first 30 days. At 1 year, there were no deaths in the female arm but nine deaths (6.0%) were observed in males, two of which were AAA related (1.3%). Through 1 year, there were eight type IA endoleaks (one female, seven males; P = .27) and three cases with limb occlusion (one female, two males). There were no reports of migration, AAA rupture, or surgical conversion through the end of follow-up.

CONCLUSIONS

Despite more complex aortic morphology in females than males, EVAR with a low-profile stent graft was associated with comparable procedural and perioperative outcomes through 1 year between the sexes.

Screening women aged 65 years or over for abdominal aortic aneurysm: a modelling study and health economic evaluation

BACKGROUND

Abdominal aortic aneurysm (AAA) screening programmes have been established for men in the UK to reduce deaths from AAA rupture. Whether or not screening should be extended to women is uncertain.

OBJECTIVE

To evaluate the cost-effectiveness of population screening for AAAs in women and compare a range of screening options.

DESIGN

A discrete event simulation (DES) model was developed to provide a clinically realistic model of screening, surveillance, and elective and emergency AAA repair operations. Input parameters specifically for women were employed. The model was run for 10 million women, with parameter uncertainty addressed by probabilistic and deterministic sensitivity analyses.

SETTING

Population screening in the UK.

PARTICIPANTS

Women aged ≥ 65 years, followed up to the age of 95 years.

INTERVENTIONS

Invitation to ultrasound screening, followed by surveillance for small AAAs and elective surgical repair for large AAAs.

MAIN OUTCOME MEASURES

Number of operations undertaken, AAA-related mortality, quality-adjusted life-years (QALYs), NHS costs and cost-effectiveness with annual discounting.

DATA SOURCES

AAA surveillance data, National Vascular Registry, Hospital Episode Statistics, trials of elective and emergency AAA surgery, and the NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP).

REVIEW METHODS

Systematic reviews of AAA prevalence and, for elective operations, suitability for endovascular aneurysm repair, non-intervention rates, operative mortality and literature reviews for other parameters.

RESULTS

The prevalence of AAAs (aortic diameter of ≥ 3.0 cm) was estimated as 0.43% in women aged 65 years and 1.15% at age 75 years. The corresponding attendance rates following invitation to screening were estimated as 73% and 62%, respectively. The base-case model adopted the same age at screening (65 years), definition of an AAA (diameter of ≥ 3.0 cm), surveillance intervals (1 year for AAAs with diameter of 3.0-4.4 cm, 3 months for AAAs with diameter of 4.5-5.4 cm) and AAA diameter for consideration of surgery (5.5 cm) as in NAAASP for men. Per woman invited to screening, the estimated gain in QALYs was 0.00110, and the incremental cost was £33.99. This gave an incremental cost-effectiveness ratio (ICER) of £31,000 per QALY gained. The corresponding incremental net monetary benefit at a threshold of £20,000 per QALY gained was -£12.03 (95% uncertainty interval -£27.88 to £22.12). Almost no sensitivity analyses brought the ICER below £20,000 per QALY gained; an exception was doubling the AAA prevalence to 0.86%, which resulted in an ICER of £13,000. Alternative screening options (increasing the screening age to 70 years, lowering the threshold for considering surgery to diameters of 5.0 cm or 4.5 cm, lowering the diameter defining an AAA in women to 2.5 cm and lengthening the surveillance intervals for the smallest AAAs) did not bring the ICER below £20,000 per QALY gained when considered either singly or in combination.

LIMITATIONS

The model for women was not directly validated against empirical data. Some parameters were poorly estimated, potentially lacking relevance or unavailable for women.

CONCLUSION

The accepted criteria for a population-based AAA screening programme in women are not currently met.

FUTURE WORK

A large-scale study is needed of the exact aortic size distribution for women screened at relevant ages. The DES model can be adapted to evaluate screening options in men.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020444 and CRD42016043227.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Secondary Endovascular Aneurysm (EVAS) Sealing in Combination With Chimney Grafts to Treat Failed Chimney EVAS

Purpose: To describe a proximal extension of a failed chimney endovascular aneurysm sealing repair (chEVAS) using a chEVAS-in-chEVAS procedure in 2 cases with successful treatment outcome at 2-year follow-up. Case Report: Two patients with an infrarenal abdominal aortic aneurysm were treated with an elective chEVAS procedure with 1 chimney stent for a unilateral renal artery. At 18 and 24 months, respectively, both patients showed aneurysm growth with an associated decrease in proximal seal. Both patients were treated with a secondary chEVAS procedure, consisting of chimney stent-graft placement in the contralateral renal and the superior mesenteric arteries combined with proximal extension of the in situ chimney stent-graft and the Nellix stents. Two-year follow-up demonstrated successful aneurysm exclusion with a patent stent configuration. Conclusion: A type Ia endoleak after chEVAS can be successfully repaired with a chEVAS-in-chEVAS procedure.

Secondary Endovascular Aneurysm (EVAS) Sealing in Combination With Chimney Grafts to Treat Failed Chimney EVAS

PURPOSE

To describe a proximal extension of a failed chimney endovascular aneurysm sealing repair (chEVAS) using a chEVAS-in-chEVAS procedure in 2 cases with successful treatment outcome at 2-year follow-up.

CASE REPORT

Two patients with an infrarenal abdominal aortic aneurysm were treated with an elective chEVAS procedure with 1 chimney stent for a unilateral renal artery. At 18 and 24 months, respectively, both patients showed aneurysm growth with an associated decrease in proximal seal. Both patients were treated with a secondary chEVAS procedure, consisting of chimney stent-graft placement in the contralateral renal and the superior mesenteric arteries combined with proximal extension of the in situ chimney stent-graft and the Nellix stents. Two-year follow-up demonstrated successful aneurysm exclusion with a patent stent configuration.

CONCLUSION

A type Ia endoleak after chEVAS can be successfully repaired with a chEVAS-in-chEVAS procedure.

Sex differences in national rates of repair of emergency abdominal aortic aneurysm

BACKGROUND

The aim of this study was to assess the sex differences in both the rate and type of repair for emergency abdominal aortic aneurysm (AAA) in England.

METHODS

Hospital Episode Statistics (HES) data sets from April 2002 to February 2015 were obtained. Clinical and administrative codes were used to identify patients who underwent primary emergency definitive repair of ruptured or intact AAA, and patients with a diagnosis of AAA who died in hospital without repair. These three groups included all patients with a primary AAA who presented as an emergency. Sex differences between repair rates and type of surgery (endovascular aneurysm repair (EVAR) versus open repair) over time were examined.

RESULTS

In total, 15 717 patients (83·3 per cent men) received emergency surgical intervention for ruptured AAA and 10 276 (81·2 per cent men) for intact AAA; 12 767 (62·0 per cent men) died in hospital without attempted repair. The unadjusted odds ratio for no repair in women versus men was 2·88 (95 per cent c.i. 2·75 to 3·02). Women undergoing repair of ruptured AAA were older and had a higher in-hospital mortality rate (50·0 versus 41·0 per cent for open repair; 30·9 versus 23·5 per cent for EVAR). After adjustment for age, deprivation and co-morbidities, the odds ratio for no repair in women versus men was 1·34 (1·28 to 1·40). The in-hospital mortality rate after emergency repair of an intact AAA was also higher among women.

CONCLUSION

Women who present as an emergency with an AAA are less likely to undergo repair than men. Although some of this can be explained by differences in age and co-morbidities, the differences persist after case-mix adjustment.

Rationale for a new registry on EVAR: The EXTREME study

To report rationale of a physician-initiated study: Expanding Indications for Treatment with Standard EVAR in Patients with Challenging Anatomies, a Multi-Centric Prospective Evaluation - EXTREME.

•

Long term result after EVAR for AAA are still considered one of the main limits to the application of this treatment.

•

According with IFU and guidelines, EVAR still has several anatomical limitation.

•

Ovation Stent-Graft is an unique devices allowing to implement the range of patients amendable to be treated by EVAR.

Morphological suitability for endovascular repair, non-intervention rates, and operative mortality in women and men assessed for intact abdominal aortic aneurysm repair: systematic reviews with meta-analysis

BACKGROUND

Prognosis for women with abdominal aortic aneurysm might be worse than the prognosis for men. We aimed to systematically quantify the differences in outcomes between men and women being assessed for repair of intact abdominal aortic aneurysm using data from study periods after the year 2000.

METHODS

In these systematic reviews and meta-analysis, we identified studies (randomised, cohort, or cross-sectional) by searching MEDLINE, Embase, CENTRAL, and grey literature published between Jan 1, 2005, and Sept 2, 2016, for two systematic reviews and Jan 1, 2009, and Sept 2, 2016, for one systematic review. Studies were included if they were of both men and women, with data presented for each sex separately, with abdominal aortic aneurysms being assessed for aneurysm repair by either endovascular repair (EVAR) or open repair. We conducted three reviews based on whether studies reported the proportion morphologically suitable (within manufacturers' instructions for use) for EVAR (EVAR suitability review), non-intervention rates (non-intervention review), and 30-day mortality (operative mortality review) after intact aneurysm repair. Studies had to include at least 20 women (for the EVAR suitability review), 20 women (for the non-intervention review), and 50 women (for the operative mortality review). Studies were excluded if they were review articles, editorials, letters, or case reports. For the operative review, studies were also excluded if they only provided hazard ratios or only reported in-hospital mortality. We assessed the quality of the studies using the Newcastle-Ottawa scoring system, and contacted authors for the provision of additional data if needed. We combined results across studies by random-effects meta-analysis. This study is registered with PROSPERO, number CRD42016043227.

FINDINGS

Five studies assessed the morphological eligibility for EVAR (1507 men, 400 women). The overall pooled proportion of women eligible (34%) for EVAR was lower than it was in men (54%; odds ratio [OR] 0·44, 95% CI 0·32-0·62). Four single-centre studies reported non-intervention rates (1365 men, 247 women). The overall pooled non-intervention rates were higher in women (34%) than men (19%; OR 2·27, 95% CI 1·21-4·23). The review of 30-day mortality included nine studies (52 018 men, 11 076 women). The overall pooled estimate for EVAR was higher in women (2·3%) than in men (1·4%; OR 1·67, 95% CI 1·38-2·04). The overall estimate for open repair also was higher in women (5·4%) than in men (2·8%; OR 1·76, 95% CI 1·35-2·30).

INTERPRETATION

Compared with men, a smaller proportion of women are eligible for EVAR, a higher proportion of women are not offered intervention, and operative mortality is much higher in women for both EVAR and open repair. The management of abdominal aortic aneurysm in women needs improvement.

FUNDING

National Institute for Health Research (UK).

Treatment of Abdominal Aortic Pathology

Abdominal aortic pathology is a diverse topic, ranging through a broad span of possible pathologies. The treatment options are equally vast, particularly with the ever-expanding endovascular techniques. In this article, we discuss management strategies for abdominal aortic aneurysms and aortic occlusive disease, because they represent some of the most common pathologies encountered in clinical scenarios.

Management of Difficult Access during Endovascular Aneurysm Repair

BACKGROUND

To describe a large single-institutional experience in managing challenging access situations during endovascular aneurysm repair (EVAR).

METHODS

Data from all patients undergoing EVAR at a tertiary academic medical center between 2009 and 2013 were collected retrospectively, including demographics, size of iliac arteries, type of device used, approach to managing difficult access (DA), and outcomes. The median follow-up was 38 months. DA was defined as iliac arteries with a diameter of less than 7 mm bilaterally. Fenestrated and snorkel repairs were excluded.

RESULTS

Of 400 EVARs performed during the study period, 191 (48%) were done in patients with DA. Of the DA patients, 35 (18.3%) underwent 42 adjuncts before the introduction of the main body device: including 15 dilators, 11 balloon angioplasties, 9 aortouniiliac devices, 3 SoloPath sheaths, 1 retroperitoneal cutdown, and 3 iliac stents. In another 29 patients, iliac stents were used to correct stenoses or kinks in the limbs after EVAR devices were deployed. The average diameter of the iliac artery used to deliver main body component was 4.6 mm in the group of patients requiring adjuncts and 5.4 mm in the remainder of the patients with small iliac arteries (P = 0.008). The median size of the main body device was 28 mm. Two cases were aborted due to inability to deliver the device. Other complications included 7 (3.6%) iliac ruptures, 3 (1.6%) instances of limb ischemia, and 5 (2.6%) patients needed early reoperation (within 30 days). Two patients (1%) had type I endoleaks at the conclusion of EVAR. During follow-up, 12 (6.3%) patients required EVAR revisions. Seven patients (3.6%) had limb thrombosis which occurred only in patients who did not have adjective procedures during the initial EVAR. Limb thrombosis and rate of revisions in patients with DA were not significantly different from the rates observed in non-DA patients. Perioperative mortality after elective repairs was 1.6% in DA patients and 0% in non-DA patients (P = 0.12).

CONCLUSIONS

EVAR can be successfully performed in patients with bilateral small iliac arteries. Adjunctive procedures might increase the technical success rate of EVAR in these patients and should definitely be considered in patients with iliac arteries less than 5 mm in diameter. Next generation and "low-profile" devices might minimize the need for adjunctive procedures and facilitate EVAR in these patients.

Clinical and Functional Impact of Hypogastric Artery Exclusion During EVAR

PURPOSE

Hypogastric artery (HA) revascularization during endovascular aneurysm repair (EVAR) is still open to debate. Moreover, exclusion-related complication rates reported in literature are not negligible. The aim of this study is to present and analyze the outcomes in patients undergoing EVAR with exclusion of 1 or both HAs at our academic center.

METHODS

We retrospectively reviewed our results in patients submitted to EVAR and needing HA exclusion, in terms of perioperative (30-day) and follow-up rates of intestinal and spinal cord ischemia, buttock claudication, buttock skin necrosis, and sexual dysfunction.

RESULTS

From January 2008 to December 2014, a total of 527 patients underwent elective standard infrarenal EVAR; among those 104 (19.7%) had iliac involvement needing HA exclusion. In 73 patients with unilateral iliac involvement (70.1%, group UH), many single HAs were excluded. Thirty-one patients (29.9%) had bilateral iliac involvement (group BH), of which 16 (51.6%) had 1 HA excluded with revascularization of the contralateral one (group BHR); in the remaining 15 patients (48.4%) both HAs were excluded (group BHE). No 30-day or follow-up aneurysm-related mortality, intestinal, or spinal cord ischemia were recorded. At 30 days, skin necrosis was observed in 2 patients. Buttock claudication and sexual dysfunction rates were significantly greater in group BHE than in group BHR (P < .05). At a mean 18.6 months follow-up (range: 4-47), buttock claudication and sexual dysfunction rates in group BHE were persistently higher than that in groups UH and BHR (P < .05); HA coil embolization was significantly associated with buttock claudication and sexual dysfunction (P < .05).

CONCLUSIONS

Whenever anatomically feasible, at least 1 HA should be salvaged in case of bilateral involvement. In case of unilateral HA exclusion, the rate of complications is not negligible. Coil embolization is related to a higher complication rate.

Endovascular aneurysm repair with the Ovation TriVascular Stent Graft System utilizing a predominantly percutaneous approach under local anaesthesia

OBJECTIVE

To present our experience with the Ovation Abdominal Stent Graft System (TriVascular Inc., Santa Rosa, CA) during endovascular aneurysm repair (EVAR) and compare results according to the type of anaesthesia.

METHODS

We conducted a single-centre retrospective study including patients who underwent EVAR using the Ovation endograft between May 2011 and July 2014. Outcome was evaluated regarding pre-, peri- and immediate postoperative and follow-up measures. Overall results are reported, while additional analysis was performed to compare the outcome between groups of patients undertaking either local or regional/general anaesthesia (LA vs RGA).

RESULTS

66 patients were included. Median follow-up was 13 months (range, 1-39 months). Median age was 72 years and median abdominal aortic aneurysm diameter was 58 mm (range, 54-100 mm). Technical success was 63 (95%), while there were 2 (3%) conversions to open surgery. A total percutaneous approach was used in 50/66 (76%) cases. Overall, 9/66 (14%) subjects suffered from any kind of morbidity. Median hospitalization was 3 days (range, 1-16 days). Immediate and midterm mortality rate was 0%. No endoleak Type I, III, IV or stent migration was observed. There were 8 (13%) Type II endoleaks. Overall, additional endovascular procedures were required in 6 (9%), while surgery was performed in 4 (6%) patients. 44 (67%) patients underwent LA and 22 (23%) RGA. Differences between groups were significant for procedural time (85 vs 107 min; p < 0.001), percutaneous access (91% vs 45%; p < 0.001) and systematic complications (2.3% vs 14%; p = 0.05).

CONCLUSION

EVAR with the use of the Ovation endograft shows promising short-term and midterm results regarding safety and effectiveness. Completion of the procedures under LA using a total percutaneous approach seems advantageous and may be used in routine practice.

ADVANCES IN KNOWLEDGE

The Ovation Abdominal Stent Graft System is an ultra-low profile stent graft system that allows percutaneous deployment for EVAR and offers excellent overall efficacy and safety. Totally percutaneous EVAR under LA seems advantageous and may be used as a routine with this specific endograft.

Changes in suprarenal and infrarenal aortic angles after endovascular aneurysm repair

Purpose

We investigated whether suprarenal and infrarenal aortic angles change after the endovascular aneurysm repair (EVAR) procedure and during follow-up, and investigated the correlation between infrarenal aortic angle after EVAR and type Ia endoleaks.

Methods

Data collected on 70 EVAR procedures for a fusiform infrarenal aortic aneurysm performed between May 2006 and December 2012 were supplemented with a retrospective review of charts and radiographs.

Results

The greater the preoperative infrarenal aortic angle, the greater the suprarenal aortic angle (r = 0.72, P < 0.001). The infrarenal aortic angle decreased after the EVAR procedure and continued to decrease slowly thereafter (all P < 0.001). Suprarenal aortic angle decreased immediately after the EVAR procedure and continued to decrease during the first month (P < 0.001). No differences in angulation were observed based on stent graft type. Type Ia endoleaks occurred with significantly greater incidence in patients with a larger post EVAR infrarenal angle (P = 0.037).

Conclusion

The infrarenal aortic angle decreased significantly immediately after the EVAR procedure and continued to decrease slowly thereafter. Suprarenal aortic angle decreased immediately after the EVAR procedure and continued to decrease during the first month. We found a correlation between infrarenal and suprarenal aortic angle. Type Ia endoleaks occurred with greater incidence in patients with a larger infrarenal angle immediately after EVAR.

Immediate and two-year outcomes after EVAR in "on-label" and "off-label" neck anatomies using different commercially available devices. analysis of the experience of two Italian vascular centers

BACKGROUND

Endovascular aneurysm repair (EVAR) has fast become the therapeutic strategy of choice for abdominal aortic aneurysms (AAAs). Nowadays, the most important limit to the effectiveness of this technique is represented by complex anatomical situations, especially regarding the morphology of the proximal sealing zone. The aim of this study was to evaluate the 2-year outcome of unselected, real-world patients with "off-label" (off-L) proximal necks treated in 2 high-volume Italian vascular centers.

METHODS

A double-center study was conducted on a prospectively compiled computerized database between January 2010 and December 2011. One hundred and ninety-six consecutive elective surgery patients were analyzed and divided into 2 groups ("on-label" [on-L] and "off-L" necks) on the basis of their aortic neck anatomy. The neck was classified as an "off-L neck" in the presence of: (1) a noncylindrical neck, (2) an angulated neck, (3) a short neck, and (4) an enlarged neck. The end points were 30-day and 2-year technical and clinical success, evaluated in terms of freedom from reintervention and death.

RESULTS

One hundred and thirty-three elective patients were treated by standard EVAR in the presence of an "off-L" proximal neck anatomy. Technical success was achieved in all cases in both groups. Six (9.5%) unplanned adjunctive procedures were necessary in the on-L group and 16 (12%) in the off-L group (P = ns). Perioperative endoleaks, reinterventions, stent-graft migration rates, and AAA-related deaths were null. A multivariate analysis was performed to evaluate the subgroups of patients with 2 or > 2 anatomic factors that indicate a challenging neck. In patients with 2 such factors, a significant difference was observed in terms of intraoperative adjunctive procedures, intraoperative endoleaks, and all-cause mortality: 26.7% vs. 9.9% (P = 0.048), 6.7% vs. 0.5% (P = 0.023), and 13.3% vs. 1.1% (P = 0.0012), respectively. The same differences became increasingly evident when analyzing patients with > 2 criteria: 50% vs. 10% (P = 0.0022), 16.7% vs. 0.5% (P < 0.001), and 16.7% vs. 1.0% (P = 0.01). No AAA-related deaths or AAA ruptures were reported in either group at the end of the 2-year follow-up. High-flow endoleaks, stent-graft migration, and, consequently, reintervention were more frequent in the off-L group, but none of these parameters reached statistical significance.

CONCLUSIONS

Our experience seems to show that the off-L use of EVAR could be considered effective for the treatment of patients unfit for open surgery. In patients with more than one anatomical proximal neck feature contraindicating open surgery, the rate of immediate complications and reinterventions was higher, but this did not affect the clinical benefit and success at 2-year follow-up.

Endovascular aneurysm repair: a perioperative perspective

Endovascular aneurysm repair (EVAR), has surpassed open repair as the technique of choice in many centres in response to several large studies which showed significantly improved 30-day mortality. While several multicentre EVAR trials looked at surgical outcomes, very few have specifically investigated the effect of anaesthetic techniques or perioperative care of these patients. The purpose of this review to is to present some of the current evidence for the different aspects of perioperative management of patients undergoing EVAR. This includes surgical considerations, pre-operative assessment, and choice of anaesthetic technique as well as pharmacological protective strategies.

Minilaparotomy abdominal aortic aneurysm repair in the era of minimally invasive vascular surgery: preliminary results

BACKGROUND

This study aimed to evaluate the early post-operative clinical impact of minimal incision aortic surgery (MIAS) for infrarenal abdominal aortic aneurysm (AAA) repair in comparison with the standard open repair.

METHODS

A case-control study was conducted. Patients of groups A (19 patients) and B (18 patients) were treated with the MIAS technique and the standard open method, respectively.

RESULTS

There were significant differences between the two groups in fluid resuscitation during the operation. Post-operatively, there were significant differences between groups A and B in the time until starting liquid diet (2 +/- 0.74 versus 3.55 +/- 0.85 post-operative days (PD), respectively; P < 0.05), the time until starting the solid diet (3.05 +/- 0.77 versus 5.11 +/- 0.75 PD, respectively; P < 0.05), the time of ambulation (2 +/- 0.74 versus 3.4 +/- 0.98 PD, respectively; P < 0.05) and in the hospital length of stay (4 +/- 0.81 versus 9.7 +/- 2.66 days, respectively; P < 0.05).

CONCLUSIONS

The MIAS technique, for repair of infrarenal aortic aneurysms, is a safe and feasible procedure that combines the early advantages of endovascular repair with the long-term advantages of the traditional open repair.

Long-term results of balloon-expandable LifePath endografts in abdominal aortic aneurysm: a single-center experience

OBJECTIVE

This retrospective single-center study analyzed long-term results after LifePath (Edwards Lifesciences LLC, Irvine, Calif) endoprosthesis implantation for abdominal aortic aneurysm (AAA), primarily focusing on the wire form fracture issue and consecutive endoleak rate.

METHODS

Between 1999 and 2004, all consecutive patients with LifePath AAA devices in our institution were included in the retrospective analysis. All patients had computed tomography angiography (CTA) imaging preoperatively and image postprocessing. The follow-up using CTA imaging specifically addressed material fatigue (wire form fractures) resulting in migrations and type I endoleaks.

RESULTS

During the 6-year study period, which included the 1-year withdrawal and redesign of the device, 51 patients were treated with LifePath AAA endografts. The 30-day mortality was 0%. The perioperative 30-day morbidity was 9.8%. One patient required a primary conversion due to misdeployment of the iliac limbs within the graft main body. The primary endoleak rate was 20.56% (type I, 2%; type II, 19.6%). During the mean follow-up of 40.7 months, 12 patients died, six were lost to follow-up, and 32 underwent subsequent CTA imaging. Eight patients (25%) demonstrated a proximal type I endoleak, seven (22%) had a type II endoleak, and three had a type III endoleak (9%). In nine patients (28.1%), wire form fractures could be detected at image postprocessing. Four patients required a secondary conversion due to endoleak and aneurysm growth (2 type I endoleaks and 2 type III endoleaks).

CONCLUSION

Wire form fracture is the major structural problem in the LifePath balloon-expandable endograft device, resulting in a significant endoleak rate. We must caution those patients with a LifePath device in-situ that careful follow-up must be performed due to material fatigue and they should consider secondary conversion.