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Chen Y, Zhang L, Liu Z, Bi J, Niu F, Zhang X, Lu Q, Dai X. Fibrin Glue Sac Filling for Preventing Type II Endoleak, Short-Term Outcomes of a Prospective Randomized Controlled Trial. J Endovasc Ther 2024; 31:1005-1012. [PMID: 36942722 DOI: 10.1177/15266028231159245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Type II endoleak (T2EL) worsens the long-term results of endovascular aneurysm repair (EVAR). How to prevent T2ELs remains controversial. This study aimed to evaluate the efficacy and safety of fibrin glue sac filling (FGSF) to prevent T2ELs after EVAR. METHODS A prospective randomized controlled trial was conducted. Patients were randomly divided into group A (standard EVAR + FGSF) and group B (standard EVAR). The follow-up plans included outpatient or telephone consultation at 1 and 3 months and computed tomography (CT) angiography at 6 months, 1 year, and once a year after EVAR. RESULTS A total of 64 abdominal aortic aneurysm (AAA) patients were randomized to the 2 groups. All patients were followed up for more than 6 months. The 2 groups showed similar baseline characteristics. The rate of T2ELs on immediate angiography in group A (9.6%) was significantly lower than that in group B (33.3%, p=0.033). Moreover, the sac area change was significantly reduced in group A at 6 months after EVAR (p=0.021). However, T2EL incidence was similar at the 6-month (p=0.055) and 1-year (p=0.057) follow-ups, and AAA diameter change was also similar at 1 year. There were similar operation times, radiation doses, severe adverse events (SAEs), and reinterventions between the 2 groups. CONCLUSION Fibrin glue sac filling could prevent short-term type II endoleaks and promote AAA shrinkage after 6 months. The FGSF procedure is swift and straightforward; however, patients are at risk of bowel ischemia, especially after previous bowel resections or concomitant superior mesenteric artery (SMA) disease. CLINICAL IMPACT Standard endovascular aneurysm repair (EVAR) couldn't prevent type II endoleak (T2EL). In this study, we found fibrin glue sac filling (FGSF) could prevent T2EL and promote AAA shrinkage in a short term. And the FGSF procedure is easy, it will be a useful supplement to standard EVAR for clinicians. And FGSF might have potential usefulness on ruptured aneurysms, although without direct evidence.Fibrin glue is often used to hemostasis and tissue adhesion in surgical patients and burn patients, we firstly carry out a randomized controlled study and prove that fibrin glue sac filling could prevent T2EL and promote sac remodeling.
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Affiliation(s)
- Yonghui Chen
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Lei Zhang
- CPLA, Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zongwei Liu
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jiaxue Bi
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Fang Niu
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaoxing Zhang
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Qingsheng Lu
- CPLA, Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Xiangchen Dai
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
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Holden A, Hill AA, Khashram M, Heyligers JMM, Wiersema AM, Hayes PD, Reijnen MMPJ. One-year follow-up after active aortic aneurysm sac treatment with shape memory polymer devices during endovascular aneurysm repair. J Vasc Surg 2024; 79:1090-1100.e4. [PMID: 38185214 DOI: 10.1016/j.jvs.2023.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/28/2023] [Accepted: 12/30/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE To determine the safety and efficacy of treating abdominal aortic aneurysm (AAA) sacs with polyurethane shape memory polymer (SMP) devices during endovascular aneurysm repair (EVAR), using a technique to fully treat the target lumen after endograft placement (aortic flow volume minus the endograft volume). SMP devices self-expand in the sac to form a porous scaffold that supports thrombosis throughout its structure. METHODS Two identical prospective, multicenter, single-arm studies were conducted in New Zealand and the Netherlands. The study population was adult candidates for elective EVAR of an infrarenal AAA (diameter of ≥55 mm in men and ≥50 mm in women). Key exclusion criteria were an inability to adequately seal a common iliac artery aneurysm, patent sac feeding vessels of >4 mm, and a target lumen volume of <20 mL or >135 mL. Target lumen volumes were estimated by subtracting endograft volumes from preprocedural imaging-based flow lumen volumes. SMP devices were delivered immediately after endograft deployment via a 6F sheath jailed in a bowed position in the sac. The primary efficacy end point was technical success, defined as filling the actual target lumen volume with fully expanded SMP at the completion of the procedure. Secondary efficacy outcome measures during follow-up were the change in sac volume and diameter, rate of type II endoleak and type I or III endoleaks, and the rate of open repair and related reinterventions, with data collection at 30 days, 6 months, and 1 year (to date). Baseline sac volumes and diameters for change in sac size analyses were determined from 30-day imaging studies. Baseline and follow-up volumes were normalized by subtraction of the endograft volume. RESULTS Of 34 patients treated with SMP devices and followed per protocol, 33 patients were evaluable at 1 year. Preprocedural aneurysm volume was 181.4 mL (95% confidence interval [CI], 150.7-212.1 mL) and preprocedural aneurysm diameter was 60.8 mm (95% CI, 57.8-63.9 mm). The target lumen volume was 56.3 mL (95% CI, 46.9-65.8 mL). Technical success was 100% and the ratio of SMP fully expanded volume to estimated target lumen volume was 1.4 ± 0.3. Baseline normalized sac volume and diameter were 140.7 mL (95% CI, 126.6-154.9 mL) and 61.0 mm (95% CI, 59.7-62.3 mm). The adjusted mean percentage change in normalized volume at 1 year was -28.8% (95% CI, -35.3 to -22.3%; P < .001). The adjusted mean change in sac diameter at 1 year was -5.9 mm (95% CI, -7.5 to -4.4 mm; P < .001). At 1 year, 81.8% of patients (95% CI, 64.5%-93.0%) achieved a ≥10% decrease in normalized volume and 57.6% of patients (95% CI, 39.2%-74.5%) achieved a ≥5 mm decrease in diameter. No device- or study procedure-related major adverse events occurred through 1 year after the procedure. CONCLUSIONS Treatment of AAA sacs with SMP devices during EVAR resulted in significant sac volume and diameter regression at 1 year with an acceptable safety profile in this prospective study.
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Affiliation(s)
- Andrew Holden
- Department of Interventional Radiology, Auckland City Hospital, Auckland, New Zealand.
| | - Andrew A Hill
- Vascular Services, Auckland City Hospital, Auckland, New Zealand
| | - Manar Khashram
- Department of Vascular & Endovascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Jan M M Heyligers
- Department of Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Arno M Wiersema
- Department of Surgery, Dijklander Ziekenhuis, Hoorn, 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
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Miura S, Kurimoto Y, Maruyama R, Nojima M, Sasaki K, Masuda T, Nishioka N, Naraoka S. Injection of n-Butyl-2-Cyanoacrylate into the Abdominal Aortic Aneurysm Sac during Endovascular Aortic Repair to Prevent Type II Endoleaks Caused by Lumbar Arteries. J Vasc Interv Radiol 2024; 35:676-686. [PMID: 38215817 DOI: 10.1016/j.jvir.2023.12.573] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 11/23/2023] [Accepted: 12/02/2023] [Indexed: 01/14/2024] Open
Abstract
PURPOSE To evaluate midterm results of whether the strategy to occlude target lumbar arteries using n-butyl-2-cyanoacrylate (nBCA) injection during endovascular aneurysm repair (EVAR) reduced the incidence of Type II endoleak (T2EL) after EVAR. MATERIALS AND METHODS Between 2013 and 2020, 187 patients underwent EVAR; 106 in the treatment group received nBCA injection during EVAR, whereas 81 in the historical control group did not. The incidence of T2EL at 7 days, need for reintervention, and post-EVAR aneurysmal shrinkage were compared between the groups. RESULTS Between the treatment group and the control group, significant differences were achieved in the incidence of T2EL (2.8% vs 28.4%; P < .0001) and decreased aneurysmal diameter was observed at 1 year after EVAR (-5.2 vs -3.8 mm; P = .034). In multivariate analysis, nBCA injection (odds ratio [OR], 0.04; P = .001) and younger age (OR, 0.92; P = .036) were significantly associated with a reduced incidence of T2EL. As a possible adverse event associated with nBCA injection, 2 cases of transient lower-limb motor dysfunction (1.9%) were observed. Propensity score analysis revealed that the treatment group had a significantly lower incidence of T2EL than that in the control group (P = .0002) even though there was no difference in the incidence of inferior mesenteric artery coil embolization between the groups. The survival rate without aneurysm sac enlargement (100.0% vs 69.8%; P = .014) and the reintervention-free rate (100.0% vs 63.1%; P = .034) in the treatment group were significantly higher than those in the control group. CONCLUSIONS Concomitant nBCA injection can provide durable EVAR without T2EL, as supported by the avoidance of reintervention associated with aneurysm sac enlargement.
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Affiliation(s)
- Shuhei Miura
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan.
| | - Yoshihiko Kurimoto
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
| | - Ryushi Maruyama
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
| | - Masanori Nojima
- Institute of Medical Science Hospital, University of Tokyo, Tokyo, Japan
| | - Keita Sasaki
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
| | - Takahiko Masuda
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
| | - Naritomo Nishioka
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
| | - Syuichi Naraoka
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
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Knappich C, Kirchhoff F, Fritsche MK, Egert-Schwender S, Wendorff H, Kallmayer M, Haller B, Hyhlik-Duerr A, Reeps C, Eckstein HH, Trenner M. Endovascular aortic repair with sac embolization for the prevention of type II endoleaks (the EVAR-SE study): study protocol for a randomized controlled multicentre study in Germany. Trials 2024; 25:17. [PMID: 38167068 PMCID: PMC10759747 DOI: 10.1186/s13063-023-07888-8] [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: 10/01/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Beyond a certain threshold diameter, abdominal aortic aneurysms (AAA) are to be treated by open surgical or endovascular aortic aneurysm repair (EVAR). In a quarter of patients who undergo EVAR, inversion of blood flow in the inferior mesenteric artery or lumbar arteries may lead to type II endoleak (T2EL), which is associated with complications (e.g. AAA growth, secondary type I endoleak, rupture). As secondary interventions to treat T2EL often fail and may be highly invasive, prevention of T2EL is desirable. The present study aims to assess the efficacy of sac embolization (SE) with metal coils during EVAR to prevent T2EL in patients at high risk. METHODS Over a 24-month recruitment period, a total of 100 patients undergoing EVAR in four vascular centres (i.e. Klinikum rechts der Isar of the Technical University of Munich, University Hospital Augsburg, University Hospital Dresden, St. Joseph's Hospital Wiesbaden) are to be included in the present study. Patients at high risk for T2EL (i.e. ≥ 5 efferent vessels covered by endograft or aneurysmal thrombus volume <40%) are randomized to one group receiving standard EVAR and another group receiving EVAR with SE. Follow-up assessments postoperatively, after 30 days, and 6 months involve contrast-enhanced ultrasound scans (CEUS) and after 12 months an additional computed tomography angiography (CTA) scan. The presence of T2EL detected by CEUS or CTA after 12 months is the primary endpoint. Secondary endpoints comprise quality of life (quantified by the SF-36 questionnaire), reintervention rate, occurrence of type I/III endoleak, aortic rupture, death, alteration of aneurysm volume, or diameter. Standardized evaluation of CTA scans happens through a core lab. The study will be terminated after the final follow-up visit of the ultimate patient. DISCUSSION Although preexisting studies repeatedly indicated a beneficial effect of SE on T2EL rates after EVAR, patient relevant outcomes have not been assessed until now. The present study is the first randomized controlled multicentre study to assess the impact of SE on quality of life. Further unique features include employment of easily assessable high-risk criteria, a contemporary follow-up protocol, and approval to use any commercially available coil material. Overcoming limitations of previous studies might help SE to be implemented in daily practice and to enhance patient safety. TRIAL REGISTRATION ClinicalTrials.gov NCT05665101. Registered on 23 December 2022.
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Affiliation(s)
- Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, 81675, Germany.
| | - Felix Kirchhoff
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, 81675, Germany
| | - Marie-Kristin Fritsche
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, 81675, Germany
| | - Silvia Egert-Schwender
- Münchner Studienzentrum, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Heiko Wendorff
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, 81675, Germany
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, 81675, Germany
| | - Bernhard Haller
- Klinikum rechts der Isar, Institute of AI and Informatics in Medicine, Technical University of Munich, Munich, Germany
| | | | - Christian Reeps
- Division of Vascular and Endovascular Surgery, Department for Visceral, Thoracic and Vascular Surgery, Medical Faculty Carl Gustav Carus and University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, 81675, Germany
| | - Matthias Trenner
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, 81675, Germany
- Division of Vascular Medicine, St. Josefs Hospital, Wiesbaden, Germany
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Massmann A, Fries P, Shayesteh-Kheslat R, Buecker A, Berg P, Frenzel F. Feasibility of aortic aneurysm sac embolization using a novel shape memory polymer embolic device. Eur Radiol Exp 2023; 7:12. [PMID: 37009937 PMCID: PMC10068687 DOI: 10.1186/s41747-023-00328-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 01/30/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND We investigated the feasibility of aneurysm sac embolization using a novel self-expanding porous shape memory polymer (SMP) device during endovascular aortic abdominal or thoracic aneurysm repair (EVAR). METHODS Retrospective analysis of consecutive patients treated at 2 centers in Germany. Patients were treated from January 2019 to July 2021 with follow-up at 7 days and 3, 6, and 12 months. Aneurysm sacs were implanted with SMP devices immediately following endograft placement during the same procedure. Primary endpoint was technically successful SMP-device deployment into the aneurysm sac outside the endograft. Secondary endpoints were changes in aneurysm volume and associated complications (e.g., endoleaks). RESULTS We included 18 patients (16 males), aged 72 ± 9 years, achieving 100% technical success. Mean preprocedure aortic aneurysm sac volume was 195 ± 117 mL with a perfused aneurysm volume of 97 ± 60 mL. A mean of 24 ± 12 SMP devices per patient were used (range 5-45, corresponding to 6.25-56.25 mL expanded embolic material volume). All evaluable patients exhibited sac regression except 2 patients yet to reach 3-month follow-up. At mean 11 ± 7 months (range 3-24), change in aneurysm volume from baseline was -30 ± 21 mL (p < 0.001). In 8 patients, aneurysm regression was observed despite type 2 endoleaks in 6 and type 1A endoleaks in 2, none of them requiring further intervention to date. No morbidity or mortality related to this treatment occurred. CONCLUSIONS SMP devices for aortic aneurysm sac embolization during endovascular repair appear feasible and safe in this small case series. Prospective studies are needed. KEY POINTS • Shape memory polymer is a novel, self-expanding, porous, and radiolucent embolic device material. • Aortic aneurysm sacs were treated with polymer devices immediately following endograft placement. • Aortic aneurysm sac regression was observed in all patients with over 3-month follow-up. • Aortic aneurysm sac regression was observed even in the presence of endoleaks.
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Affiliation(s)
- Alexander Massmann
- Radiology and Nuclear Medicine, Bosch Health Campus, Robert-Bosch-Krankenhaus, Auerbachstraße 110, 70376, Stuttgart, Germany.
| | - Peter Fries
- Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Roushanak Shayesteh-Kheslat
- Clinic for General, Visceral, Vascular and Pediatric Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Arno Buecker
- Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Patrick Berg
- Clinic for Vascular Surgery, Katholisches Karl-Leisner-Klinikum, Kevelaer, Germany
| | - Felix Frenzel
- Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
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Mostafa K, Schierenbeck M, Trentmann J, Gottschalk H, Andersson J, Pfarr J, Sieren M, Jansen O, Schäfer PJ. Endovascular Aneurysm Sac Embolization for Treatment of Ruptured Aneurysms in the Aortoiliac Segment Using N-Butyl-Cyanoacrylate. Life (Basel) 2023; 13:life13040919. [PMID: 37109448 PMCID: PMC10145858 DOI: 10.3390/life13040919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/09/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Background Aneurysmal rupture in the aortoiliac segment is a severe, life-threatening condition. Nowadays, in addition to surgical treatment, the implantation of a covered stent graft constitutes a feasible, minimally invasive treatment option. A novel approach is the add-on of transarterial aneurysm sac embolization with N-butyl-cyanoacrylate (NBCA). Here, we report our experience of performing this add-on embolization procedure after endovascular aneurysm repair for complex ruptured aneurysms of the aortoiliac segment. Material and Methods We describe six patients (mean age of 75.2 years; all male) with ruptured aneurysms in the visceral aortic and aortoiliac segment in whom a high-volume transarterial aneurysm sac embolization was performed as an add-on therapy to the implantation of an aortic prosthesis. The aim of this add-on intervention was to achieve the definite embolization of the aneurysmal rupture site and to ensure the best possible aneurysmal sealing. We report the feasibility, technical success, and considerations of using NBCA as well as clinical and follow-up imaging results, given their availability. Results Technical success was achieved in all cases. Clinical success was achieved in four cases. No periprocedural complications or reinterventions were reported. The mean full procedure time was 107.8 min. The mean radiation dose was 12,966.1 cGy/cm2. A mean amount of 10.7 mL of NBCA mixed with lipiodol in a 1:3 to 1:5 ratio was used for all patients. Available follow-up imaging up to 36 months after the procedure showed no aneurysm progression or endoleaks. In two patients, the NBCA cast had almost fully dissolved over the course of follow-up. Conclusions Our study underscores the notion that aneurysm sac embolization using high volumes of NBCA with ethiodized oil as an embolic agent is a feasible and add-on treatment option for optimizing the exclusion of the aneurysm from patients with ruptured aneurysms in the aortoiliac segment.
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Affiliation(s)
- Karim Mostafa
- Department for Radiology and Neuroradiology, University Hospital Schleswig Holstein, Campus Kiel, 24105 Kiel, Germany
| | - Marie Schierenbeck
- Department for Radiology and Neuroradiology, University Hospital Schleswig Holstein, Campus Kiel, 24105 Kiel, Germany
| | - Jens Trentmann
- Department for Radiology and Neuroradiology, University Hospital Schleswig Holstein, Campus Kiel, 24105 Kiel, Germany
| | - Hannes Gottschalk
- Department for Radiology and Neuroradiology, University Hospital Schleswig Holstein, Campus Kiel, 24105 Kiel, Germany
| | - Julian Andersson
- Department for Radiology and Neuroradiology, University Hospital Schleswig Holstein, Campus Kiel, 24105 Kiel, Germany
| | - Julian Pfarr
- Department for Radiology and Neuroradiology, University Hospital Schleswig Holstein, Campus Kiel, 24105 Kiel, Germany
| | - Malte Sieren
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, 23569 Lübeck, Germany
- Institute of Interventional Radiology, University Hospital Schleswig-Holstein, Campus Lübeck, 23569 Lübeck, Germany
| | - Olav Jansen
- Department for Radiology and Neuroradiology, University Hospital Schleswig Holstein, Campus Kiel, 24105 Kiel, Germany
| | - Philipp J. Schäfer
- Department for Radiology and Neuroradiology, University Hospital Schleswig Holstein, Campus Kiel, 24105 Kiel, Germany
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Mathlouthi A, Yei K, Guajardo I, Al-Nouri O, Malas MB, Barleben A. Prophylactic Perigraft Arterial Sac Embolization During EVAR: Minimizing Type II Endoleaks and Improving Sac Regression. Ann Vasc Surg 2023:S0890-5096(23)00152-8. [PMID: 36906128 DOI: 10.1016/j.avsg.2023.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Type II endoleaks (ELII) are the most common complication following endovascular aneurysm repair (EVAR). Persistent type II endoleaks require continual surveillance and have been shown to increase the risk of Type I and III endoleaks, sac growth, need for intervention, conversion to open or even rupture directly or indirectly. These are often difficult to treat following EVAR and there are limited data regarding the effectiveness of prophylactic treatment of ELII. The aim of this study is to report midterm outcomes of prophylactic perigraft arterial sac embolization (pPASE) performed in patients undergoing EVAR. METHODS This is a comparison of two elective cohorts of those undergoing EVAR using the Ovation stent graft with and without prophylactic branch vessel and sac embolization. Patients who underwent pPASE at our institution had data collected in a prospective, IRB approved database. These were compared against the core lab adjudicated data from the Ovation IDE trial. Prophylactic PASE was performed at the time of EVAR with thrombin, contrast and gelfoam if lumbar or mesenteric arteries were patent. Endpoints included freedom from ELII, reintervention, sac growth, all-cause mortality (ACM) and aneurysm-related mortality (ARM). RESULTS Thirty-six patients (13.1%) underwent pPASE, while 238 patients (86.9%) had standard EVAR. Median follow-up was 56 months (IQR 33-60). The 4-year freedom from ELII estimates were 84% for the pPASE vs 50.7% for the standard EVAR group (P=0.0002). All aneurysms in the pPASE group remained stable in size or demonstrated regression, whereas aneurysm sac expansion was seen in 10.9% of the standard EVAR group, P=0.03. At 4 years, mean AAA diameter decreased by 11mm (95% CI 8-15) in the pPASE group vs 5mm (95%CI 4-6) for the standard EVAR group, P=0.0005. There were no differences in the 4-year freedom from ACM and ARM. However, the difference in reintervention for ELII trended toward significance (0.0% vs 10.7%, P=0.1). On multivariable analysis, pPASE was associated with a 76% reduction in ELII [aHR(95%CI): 0.24 (0.08-0.65), P=0.005]. CONCLUSION These results suggest that pPASE in those undergoing EVAR is safe and effective in the prevention of EII and significantly improves sac regression over standard EVAR while minimizing the need for reintervention.
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Affiliation(s)
| | - Kevin Yei
- University of California San Diego, La Jolla, CA
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Chen Q, Zhang Y, Lei K, Fu L, Zhang D, Sun W, Shi C, Niu Q. Efficacy and safety of prophylactic intraoperative sac embolization in EVAR for abdominal aortic aneurysm: A meta-analysis. Front Surg 2023; 9:1027231. [PMID: 36684193 PMCID: PMC9852339 DOI: 10.3389/fsurg.2022.1027231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/24/2022] [Indexed: 01/09/2023] Open
Abstract
Objective We aimed to investigate the effectiveness and safety of prophylactic sac embolization during endovascular aneurysm repair (EVAR) in patients suffering from abdominal aortic aneurysms. Methods We performed a systematic literature search of PubMed, Web of Science, EMbase, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, Wanfang and China Biomedical Literature Database (CBM) to identify studies evaluating the outcomes of sac embolization vs. no embolization among patients who had received EVAR. The time limit of the search was from the establishing database to July 22, 2022. Outcome measures involved the type II endoleak rate, the other endoleak rate, the reintervention rate, mortality, and operation time. Fixed (no heterogeneity) or random effects models were constructed for each outcome. The outcomes are represented as the odds ratio (OR) with a 95% confidence interval (CI). Results Among the 2,622 studies screened, 13 studies involving 747 participants were included in the review. The incidence of early-term type II endoleak (OR = 0.2, 95% CI (0.13,0.31), P < 0.00001), mid-term type II endoleak (OR = 0.23, 95% CI (0.15,0.37), P < 0.00001), late-term type II endoleak (OR = 0.27, 95% CI (0.16,0.46), P < 0.00001) and reintervention (OR = 0.50, 95% CI (0.37,0.78), P = 0.002) within the sac embolization group were significantly lower than those in the non-embolization group. No significant differences were observed between the two groups were found for the other endoleak rates (OR = 0.67, 95% CI (0.34,1.32), P = 0.25), mortality (OR = 0.64, 95% CI (0.25,1.66), P = 0.36) and operation time operation (MD = 5.76, 95% CI (-8.30,19.83), P = 0.42). Conclusions EVAR combined with sac embolization effectively reduces the incidence of type II endoleak and the reintervention rate without enhancing the operation time. Therefore, more high-quality studies are still needed for validation due to the limited amount and quality of included literature. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022365648.
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Affiliation(s)
- Quan Chen
- Department of Intervention and Vascular Surgery, Dongguan People's Hospital, Dongguan, Guangdong, China
| | - Yuan Zhang
- The First Clinical Medical College of Gansu University of Chinese Medicine(Gansu Provincial Hospital), Lanzhou, Gansu, China
| | - Kangqing Lei
- The First Clinical Medical College of Gansu University of Chinese Medicine(Gansu Provincial Hospital), Lanzhou, Gansu, China
| | - Liangyin Fu
- The First Clinical Medical College of Gansu University of Chinese Medicine(Gansu Provincial Hospital), Lanzhou, Gansu, China
| | - Dengxiao Zhang
- The First Clinical Medical College of Gansu University of Chinese Medicine(Gansu Provincial Hospital), Lanzhou, Gansu, China
| | - Wanli Sun
- Department of Vascular Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Chaohai Shi
- Department of Vascular Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Qibing Niu
- Department of Vascular Surgery, Gansu Provincial Hospital, Lanzhou, Gansu, China,Correspondence: Qibing Niu
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Wu Y, Yin J, Hongpeng Z, Wei G. Systematic review and network meta-analysis of pre-emptive embolization of the aneurysm sac side branches and aneurysm sac coil embolization to improve the outcomes of endovascular aneurysm repair. Front Cardiovasc Med 2022; 9:947809. [PMID: 35935638 PMCID: PMC9354492 DOI: 10.3389/fcvm.2022.947809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 06/29/2022] [Indexed: 01/02/2023] Open
Abstract
Objective Previous reports have revealed a high incidence of type II endoleak (T2EL) after endovascular aneurysm repair (EVAR). The incidence of T2EL after EVAR is reduced by pre-emptive embolization of aneurysm sac side branches (ASSB) and aneurysm sac coil embolization (ASCE). This study aimed to investigate whether different preventive interventions for T2EL were correlated with suppression of aneurysm sac expansion and reduction of the re-intervention rate. Methods The PubMed, Web of Science, MEDLINE and Embase databases, and conference proceedings were searched to identify articles on EVAR with or without embolization. The study was developed in line with the Participants, Interventions, Comparisons, Outcomes, and Study design principles and was conducted and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We used network meta-analysis based on multivariate random-effects meta-analysis to indirectly compare outcomes of different strategies for embolization during EVAR. Results A total of 31 studies met all inclusion criteria and were included in the qualitative and quantitative syntheses. The included studies were published between 2001 and 2022 and analyzed a total of 18,542 patients, including 1,882 patients who received prophylactic embolization treatment during EVAR (experimental group) and 16,660 who did not receive prophylactic embolization during EVAR (control group). The effect of pre-emptive embolization of the inferior mesenteric artery (IMA) (IMA-ASSB) in preventing T2EL was similar (relative risk [RR] 1.01, 95% confidence interval [CI] 0.38–2.63) to the effects of non-selective embolization of ASSB (NS-ASSB) and ASCE (RR 0.88, 95% CI 0.40–1.96). IMA-ASSB showed a better clinical effect in suppressing the aneurysm sac expansion (RR 0.27, 95% CI 0.09–2.25 compared with NS-ASSB; RR 0.93, 95% CI 0.16–5.56 compared with ASCE) and reducing the re-intervention rate (RR 0.34, 95% CI 0.08–1.53 compared with NS-ASSB; RR 0.66, 95% CI 0.19–2.22 compared with ASCE). All prophylactic embolization strategies improved the clinical outcomes of EVAR. Conclusion Prophylactic embolization during EVAR effectively prevents T2EL, suppresses the aneurysm sac expansion, and reduces the re-intervention rate. IMA embolization demonstrated benefits in achieving long-term aneurysm sac stability and lowering the risk of secondary surgery. NS-ASSB more effectively reduces the incidence of T2EL, while IMA embolization alone or in combination with ASCE enhances the clinical benefits of EVAR. In addition, as network meta-analysis is still an indirect method based on a refinement of existing data, more studies and evidence are still needed in the future to establish more credible conclusions.
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Affiliation(s)
- Ye Wu
- Department of Vascular Surgery, First Medical Center, Chinese PLA General Hospital, Beijing, China.,Medical College of Chinese PLA, Beijing, China
| | - Jianhan Yin
- Department of Vascular Surgery, First Medical Center, Chinese PLA General Hospital, Beijing, China.,Nankai University, Tianjin, China
| | - Zhang Hongpeng
- Department of Vascular Surgery, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Guo Wei
- Department of Vascular Surgery, First Medical Center, Chinese PLA General Hospital, Beijing, China
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Aoki A, Maruta K, Omoto T, Masuda T. Midterm Outcomes of Endovascular Abdominal Aortic Aneurysm Repair with Prevention of type 2 Endoleak by Intraoperative Aortic Side Branch Coil Embolization. Ann Vasc Surg 2021; 78:180-189. [PMID: 34537351 DOI: 10.1016/j.avsg.2021.06.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The midterm results of endovascular abdominal aortic aneurysm repair (EVAR) with aortic side branch coil embolization during EVAR was evaluated. METHODS Our center began coil embolization for all patent inferior mesenteric artery (IMA) and lumbar artery (LA) with an inner diameter more than 2.0 mm during EVAR since June 2015. When four or more LA were patent, coil embolization for LA with inner diameter 2.0 mm or less was done. EVAR without aortic side branches coil embolization was performed for 59 patients prior to June 2015 (control group) and 79 patients underwent EVAR with coil embolization during EVAR (coil group). The success rate of coil embolization for IMA and LA was evaluated in coil group. The frequency of type 2 endoleak (T2EL), freedom from aneurysm sac expansion (5 mm or more) rate and the rate of the aneurysm sac shrinkage (10 mm or more) were compared between the coil and control groups. Additionally, multiple logistic regression analysis for all patients was conducted to analyze whether IMA patency and the number of patent lumbar artery at the end of EVAR were the risk factors of the aneurysm sac expansion of 5 mm or more. RESULTS The success rate of IMA coil embolization was 96.4% and that of LA was 74.5%. Compared to the control group, the frequency of T2EL was significantly lower in coil group at 7 days (1.3% vs. 60.4%, P <0.0001) and at 6 months (2.1% vs 38.2%, P <0.0001) after EVAR. The freedom from aneurysm sac expansion rate was significantly better in the coil group at 5 years (100% in coil group and 65.2% in control group, P = 0.002). The rate of aneurysm sac shrinkage was significantly better in coil group (15.5% vs. 2.0% at 1 year, 42.8% vs. 6.3% at 2 years and 53.4% vs. 17.8% at 3 years, p = 0.0007). The risk of aneurysm sac expansion of 5 mm or more was estimated to be 11 times greater when the IMA was patent, and 4.9 times greater when 3 or more LAs were patent at the end of EVAR. CONCLUSION When IMA was occluded and the number of patent LA became 2 or less by aortic side branch coil embolization during EVAR, favorable mid-term results were safely obtained and good long-term result could be expected with EVAR.
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Affiliation(s)
- Atsushi Aoki
- Department of Cardiovascular Surgery, Showa University, Shinagawa, Tokyo, Japan.
| | - Kazuto Maruta
- Department of Cardiovascular Surgery, Showa University, Shinagawa, Tokyo, Japan
| | - Tadashi Omoto
- Department of Cardiovascular Surgery, Showa University, Shinagawa, Tokyo, Japan
| | - Tomoaki Masuda
- Department of Cardiovascular Surgery, Showa University, Shinagawa, Tokyo, Japan
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Mathlouthi A, Guajardo I, Al-Nouri O, Malas M, Barleben A. Prophylactic Aneurysm Embolization during EVAR Is Safe, Improves Sac Regression and Decreases the Incidence of Type II Endoleak. Ann Vasc Surg 2021; 74:36-41. [PMID: 33549781 DOI: 10.1016/j.avsg.2020.12.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 12/16/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Clinically significant endoleaks remain costly, time-consuming, morbid and even mortal following endovascular aneurysm repair (EVAR). Perigraft arterial sac embolization (PASE) has been utilized to treat type II endoleaks (T2EL) diagnosed at the time of EVAR or after repair. Our objective was to analyze the safety and efficacy of prophylactic PASE on the incidence of T2EL and aneurysm sac regression in patients undergoing EVAR. METHODS We performed a retrospective review of prospectively maintained databases from the University of California San Diego and the San Diego Veterans Affairs hospitals between 2015 and 2019. Prophylactic PASE (pPASE) was performed at the time of EVAR with thrombin, contrast and gelfoam liquid embolic aneurysm treatment as previously described. We evaluated technical success, freedom from T2EL, freedom from reintervention, from sac expansion, from type I/III EL, from all-cause mortality (ACM), from aneurysm-related mortality and from non-target embolization (NTE). RESULTS A total of 44 patients were included in the study. Technical success was 100% and no NTE was observed. The average duration of follow-up was 14 ± 11months. In those treated and followed by CT scan, 100% of patients' aneurysms halted their growth following PASE, while 65.9% demonstrated sac regression. Mean aneurysm sac diameter decreased by 9 mm (95% CI 7-12). At 3 years, freedom from T2EL was 87.1%. Presence of T2EL did not result in aneurysm expansion during the follow-up period and thus did not require reintervention in any of these patients. Freedom from re-intervention was 83.2% for Type Ib EL and limb occlusion and all procedures were determined to be successful at the time of completion. No aneurysm-related deaths occurred during the follow-up. CONCLUSIONS PASE proves to be an effective tool in sac management for prophylaxis of endoleak and maximizing sac regression in EVAR. It is safe, effective and durable when employed in this manner in the short and medium-term and was associated with low rates of T2ELs and reinterventions and a 100% freedom from sac expansion. Further analysis is required to evaluate the long-term outcomes of this adjunctive procedure in EVAR.
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Affiliation(s)
- Asma Mathlouthi
- Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Isabella Guajardo
- Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Omar Al-Nouri
- Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Mahmoud Malas
- Department of Surgery, University of California, San Diego, La Jolla, CA
| | - Andrew Barleben
- Department of Surgery, University of California, San Diego, La Jolla, CA.
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12
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Aoki A, Maruta K, Hosaka N, Masuda T, Omoto T, Horikawa Y. Predictive Factor of the Possibility for Aortic Side Branches Coil Embolization during Endovascular Abdominal Aortic Aneurysm Repair. Ann Vasc Dis 2020; 13:240-247. [PMID: 33384725 PMCID: PMC7751085 DOI: 10.3400/avd.oa.20-00115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: Coil embolization of aortic side branches has been additionally performed to prevent type II endoleak during EVAR in our institute. In this study, we evaluated the predictive factors of the possibility for coil embolization of the inferior mesenteric artery (IMA) and lumbar artery (LA) during EVAR. Methods: Seventy-four EVAR patients during June 2015 and April 2019 were included in the study. The coil embolization procedural time for one vessel is limited to 10 min. Aortic side branches were selected with 4 Fr Shepherd hook type catheter (Medikit, Tokyo, Japan) and were embolized with Interlock (Boston Scientific, MA, USA) via microcatheter. As predictive factors, internal diameter of aortic side branches and the aortic diameter perpendicular to the origin of LA (aortic diameter) were evaluated. Results: Coil embolization was tried for 52 patent IMAs and all IMAs except two IMAs with ostial stenosis were successfully coil embolized (96.2%). Totally 190 LAs were patent and coil embolization was tried for 144 LAs. Among 144 LAs, 106 LAs (73.6%) were successfully coil embolized and the diameter was significantly longer (2.30±0.51 mm vs. 2.04±0.41 mm, p=0.007) and aortic dimeter was significantly shorter (30.0±8.1 mm vs. 40.5±11.6 mm, p<0.001) in successfully embolized LAs. Cut off value of successful LA coil embolization was 2.06 mm for internal diameter and 36.1 mm for aortic diameter by receiver operating characteristic curve analysis. Successful coil embolization rate for LAs with internal diameter longer than 2.0 mm and aortic diameter less than 36.2 mm was 90% (72 among 80 LAs). Conclusion: Coil embolization during EVAR for IMA was highly successful, if there was no calcified ostial stenosis. LA embolization was feasible especially for LAs with internal diameter ≥2.0 mm and aortic diameter ≤36.1 mm. This information would be useful to select the target vessel for aortic side branches coil embolization during EVAR. (This is a translation of Jpn J Vasc Surg 2019; 28: 389–396.)
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Affiliation(s)
- Atsushi Aoki
- Department of Cardiovascular Surgery, Showa University Hospital
| | - Kazuto Maruta
- Department of Cardiovascular Surgery, Showa University Hospital
| | | | - Tomoaki Masuda
- Department of Cardiovascular Surgery, Showa University Hospital
| | - Tadashi Omoto
- Department of Cardiovascular Surgery, Showa University Hospital
| | - Yui Horikawa
- Department of Cardiovascular Surgery, Showa University Hospital
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Gonzalez-Urquijo M, Lozano-Balderas G, Fabiani MA. Type II Endoleaks After EVAR: A Literature Review of Current Concepts. Vasc Endovascular Surg 2020; 54:718-724. [PMID: 32744153 DOI: 10.1177/1538574420945448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Endoleak is the most frequent complication following endovascular aneurysm repair, which is not present in the surgical counterpart. The most frequent type of endoleak corresponds to type II, and its natural history remains poorly understood. Therefore, their treatment continues to be a topic of debate. The vast majority of the studies found in the literature are of a retrospective nature, and there are no prospective studies comparing intervention versus a conservative approach. Future studies should aim to compare not only different approaches to resolve type II endoleak but also when should be the right time to treat them, with the primary purpose of avoiding sac rupture. The objective of this review is to provide the reader with a literature overview about type II endoleaks to help in the decision-making process on this topic.
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Affiliation(s)
| | - Gerardo Lozano-Balderas
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo León, México
| | - Mario Alejandro Fabiani
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo León, México
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14
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Barleben A, Quinones-Baldrich W, Mogannam A, Archie M, Lane JS, Malas M. Midterm evaluation of perigraft arterial sac embolization in endovascular aneurysm repair. J Vasc Surg 2020; 72:1960-1967. [PMID: 32471739 DOI: 10.1016/j.jvs.2020.01.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 01/22/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Management of clinically significant endoleaks (ELs) remains costly, time-consuming, and morbid. Unresolved ELs can result in rupture and mortality after endovascular aneurysm repair (EVAR). Perigraft arterial sac embolization (PASE) has been used to treat ELs diagnosed at the time of EVAR or during surveillance. METHODS A retrospective review of prospectively maintained databases was conducted. The databases were compiled from two institutions between 2006 and 2016. PASE was performed for type I, type II, or type III EL with a thrombin, contrast medium, and Gelfoam (Pfizer, New York, NY) slurry prepared as previously described. PASE was administered either at the time of EVAR (primary) or during surveillance (secondary). Safety end points included nontarget embolization, defined as neurologic or enteric clinical sequelae from lumbar artery or visceral artery embolization, allergic reaction, peripheral embolization, or rupture. Efficacy end points included successful resolution of EL and cessation of aneurysm sac growth on computed tomography (CT) scans with contrast enhancement. RESULTS A total of 66 patients included in the study were treated with PASE. Primary PASE was performed in 38 patients (58%) and secondary in 28 (42%). Within the total cohort, the average clinical and CT scan follow-up was 1.7 years (0.1-11.6 years). Four patients required open repair for residual high-pressure ELs (one type IIIB and three type I; 6%). Of the 95% of patients who did not require open conversion, aneurysm growth did not occur during the follow-up period. In the overall cohort, PASE was successful in 88% of type I EL and 73% of patients with type II EL. There was no evidence of recanalization after thrombosis of culprit vessel for EL. No patients suffered nontarget embolization, spinal ischemia, allergic reaction, post-EVAR rupture, or colonic ischemia. CONCLUSIONS Primary and secondary PASE proved to be a safe, effective, and durable tool in sac management in conjunction with EVAR. Treating ELs during or after EVAR with PASE has minimized the incidence of EL on CT scan and halted aneurysm growth in our cohort. Further studies are needed to confirm the long-term durability of PASE in reducing secondary interventions after EVAR.
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Affiliation(s)
- Andrew Barleben
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, Calif.
| | - William Quinones-Baldrich
- Division of Vascular and Endovaascular Surgery, Department of Surgery, University of California, Los Angeles, Calif
| | - Abid Mogannam
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, Calif
| | - Meena Archie
- Division of Vascular and Endovaascular Surgery, Department of Surgery, University of California, Los Angeles, Calif
| | - John S Lane
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, Calif
| | - Mahmoud Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, Calif
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Ohba S, Shimohira M, Hashizume T, Muto M, Ohta K, Sawada Y, Mizuno A, Nakai Y, Suda H, Shibamoto Y. Feasibility and Safety of Sac Embolization Using N-Butyl Cyanoacrylate in Emergency Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms or Isolated Iliac Artery Aneurysms. J Endovasc Ther 2020; 27:828-835. [PMID: 32436809 DOI: 10.1177/1526602820923954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the feasibility and safety of sac embolization with N-butyl cyanoacrylate (NBCA) in emergency endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (AAA) and iliac artery aneurysm (IAA) in comparison to EVAR without sac embolization. MATERIALS AND METHODS Between February 2012 and December 2019, among 44 consecutive patients with ruptured AAA or IAA, 29 underwent EVAR. Of these, 22 patients (median age 77.5 years; 18 men) had concomitant sac embolization using NBCA; the remaining 7 patients (median age 88 years; 6 men) underwent EVAR without sac embolization and form the control group. The technical success, clinical success (hemodynamic stabilization), procedure-related complications, and mortality were compared between the groups. RESULTS All EVAR procedures and embolizations were successful. The clinical success rates in the NBCA and control groups were 95% (21/22) and 71% (5/7), respectively (p=0.14). There was no complication related to the procedure. Type II endoleak occurred in 4 of 21 patients (19%) in the NBCA group vs none of the control patients. One patient (5%) died in the NBCA group vs 3 (43%) in the controls (p=0.034). CONCLUSION Sac embolization using NBCA in emergency EVAR appears to be feasible and safe for ruptured AAA and IAA.
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Affiliation(s)
- Shota Ohba
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masashi Shimohira
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takuya Hashizume
- Department of Radiology, Nagoya Kyoritsu Hospital, Nagoya, Japan
| | - Masahiro Muto
- Department of Radiology, Nagoya City East Medical Center, Nagoya, Japan
| | - Kengo Ohta
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yusuke Sawada
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Akihiro Mizuno
- Department of Cardiovascular Surgery, Nagoya City East Medical Center, Nagoya, Japan
| | - Yosuke Nakai
- Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hisao Suda
- Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yuta Shibamoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Miura S, Kurimoto Y, Maruyama R, Masuda T, Yanase Y, Iba Y, Nojima M, Yamada A. Endovascular Aortic Aneurysm Repair without Type 2 Endoleak Using Concomitant N-Butyl-2-Cyanoacrylate Injection into the Abdominal Aortic Aneurysm Sac. Ann Vasc Surg 2019; 66:110-119. [PMID: 31863949 DOI: 10.1016/j.avsg.2019.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/27/2019] [Accepted: 12/06/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The aim of this study was to evaluate our new method to occlude target lumber arteries using N-butyl-2-cyanoacrylate (NBCA) during endovascular aneurysm repair (EVAR) for prevention of type 2 endoleak (T2E). METHODS AND RESULTS Between 2013 and 2018, 176 patients who underwent EVAR for abdominal aortic aneurysm (AAA) were reviewed. Starting from October 2015, 83 patients (treatment group) underwent NBCA injection into the aneurysmal sac during EVAR. The incidence of T2E at 7 days and AAA sac diameter 12 months after EVAR were compared with those of the control group comprising 93 consecutive patients who underwent EVAR alone before 2015. The incidence of T2E at 7 days was significantly lower in the treatment group (2.4%) than in the control group (22.6%) (P < 0.001). AAA sac diameter at 12 months in the treatment group had a mean decrease of 6.6 mm as compared with the mean 4.4 mm in the control group (P = 0.026). In multivariate analysis, NBCA injection was significantly related to the reduction of incidence of T2E at 7 days (odds ratio = 11.8, P < 0.001) and a decrease in AAA sac diameter at 12 months (P < 0.001). There was no NBCA injection-related complication and reintervention in the treatment group. CONCLUSIONS NBCA injection might be safe and useful to reduce the incidence of T2Es and to prevent AAA sac expansion.
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Affiliation(s)
- Shuhei Miura
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan.
| | - Yoshihiko Kurimoto
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
| | - Ryushi Maruyama
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
| | - Takahiko Masuda
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
| | - Yohsuke Yanase
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
| | - Yutaka Iba
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
| | - Masanori Nojima
- The Institute of Medical Science Hospital, University of Tokyo, Tokyo, Japan
| | - Akira Yamada
- Department of Cardiovascular Surgery, Teine Keijinkai Hospital, Sapporo, Japan
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Li X, Huang Y, Guo P. Midterm results of periprosthetic coiling embolization in high-risk patients. J Interv Med 2019; 2:160-163. [PMID: 34805894 PMCID: PMC8562269 DOI: 10.1016/j.jimed.2019.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background With increasing interest in the prevention of type II endoleaks (EII), the aim of this study was to report midterm results on the intraoperative coiling embolization of the periprosthetic aneurysmal sac in patients at high-risk of EII. Methods A retrospective review study was conducted with 124 patients with infrarenal abdominal aortic aneurysm who accorded with the inclusion criteria, including 66 patients who underwent standard endovascular aortic aneurysm repair (Group A) and 58 patients who underwent aneurysmal sac coiling embolization (Group B). Baseline data and follow-up results were analyzed. Results A mean of 2.84 ± 1.45 coils (range 1–9) were used in Group B. The general incidence of an EII was 15.32% (19/124) at a mean follow-up time of 46.60 ± 15.14 months, with 22.7% (15/66) in Group A and 6.9% (4/58) in Group B (χ2 = 5.62; P = 0.018). Logistic multivariate analysis revealed that the independent risk factors of an EII were no sac embolization and a sac volume ≥128 cm3. The Kaplan-Meier subgroup analysis showed no difference in regard to the rate of freedom from EII between the two groups either with a larger or smaller sac. Conclusions These results suggest that periprosthetic coiling embolization in patients at high-risk of EII is safe and effective in the prevention of EII. The preventive effect seemed to be weakened when the sac volumes were taken into consideration at midterm follow-up.
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18
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Li Q, Hou P. Sac Embolization and Side Branch Embolization for Preventing Type II Endoleaks After Endovascular Aneurysm Repair: A Meta-analysis. J Endovasc Ther 2019; 27:109-116. [PMID: 31566053 DOI: 10.1177/1526602819878411] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose:To investigate the efficacy and safety of preoperative side branch embolization or intraoperative sac embolization for preventing type II endoleaks after endovascular aneurysm repair (EVAR). Materials and Methods: A systematic literature search of MEDLINE and EMBASE was performed to identify studies that evaluated the outcomes of sac embolization vs no embolization or side branch embolization vs no embolization in patients who received EVAR. Among the 904 studies screened, 17 studies with 2084 participants were included in this review. Outcome measures included the type II endoleak rate, the reintervention rate for type II endoleaks, the incidence of types I/III endoleaks, and the rate of complications. Fixed (no heterogeneity) or random effects models were constructed for each outcome; the results are presented as the odds ratio (OR) with 95% confidence interval (CI). Results: The sac embolization group had significantly lower type II endoleak (OR 0.21, 95% CI 0.13 to 0.34, p<0.001) and reintervention (OR 0.15, 95% CI 0.07 to 0.33, p<0.001) rates than the no embolization group. No significant differences between the 2 groups were found for the type I/III endoleak rate (OR 0.57, 95% CI 0.23 to 1.37, p=0.21) or complication rate (OR 1.22, 95% CI 0.32 to 4.70, p=0.77). Compared with no embolization, side branch embolization was also associated with a decrease in type II endoleak (OR 0.35, 95% CI 0.21 to 0.60, p<0.001) and reinterventions (OR 0.10, 95% CI 0.04 to 0.27, p<0.001). One severe procedure-related complication (fatal colon ischemia) was reported in the side branch embolization group. Conclusion: Sac embolization and side branch embolization are safe and effective in preventing type II endoleaks. Further randomized trials are needed to directly compare the clinical outcomes of these procedures.
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Affiliation(s)
- Qiyi Li
- Department of Vascular Surgery, Liu Zhou Worker’s Hospital, Liuzhou, Guangxi, China
| | - Peiyong Hou
- Department of Vascular Surgery, Liu Zhou Worker’s Hospital, Liuzhou, Guangxi, China
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19
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Long-term outcome of sac filling with fibrin sealant after endovascular aneurysm repair of abdominal aortic aneurysm with challenging aortic neck anatomy. J Vasc Surg 2019; 70:471-477. [DOI: 10.1016/j.jvs.2018.10.113] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 10/22/2018] [Indexed: 11/18/2022]
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20
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Lo Sapio P, Chisci E, Gori AM, Botteri C, Turini F, Michelagnoli S, Marcucci R. Tight systolic blood pressure control with combination therapy decreases type 2 endoleaks in patients undergoing endovascular aneurysm repair. Int J Cardiol 2019; 285:97-102. [PMID: 30926159 DOI: 10.1016/j.ijcard.2019.02.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 01/29/2019] [Accepted: 02/27/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysm (AAA) disease. However, the survival advantage is lost in the long term due the occurrence of endoleaks affecting the late rupture of aneurism sac. Few data are available on the role of blood pressure control in affecting the incidence of type 2 endoleaks in patients undergoing EVAR. OBJECTIVE Aim of this study was to evaluated whether systolic blood pressure (SBP) control to target 130 mmHg reached after preoperative cardiology consultant might decrease the incidence of type II endoleak(T2E), sac expansion and related aortic reintervention after elective endovascular aneurysm repair(EVAR). METHODS We analyzed 386 patients undergoing EVAR between 2008 and 2016. The primary endpoints were T2E, sac expansion and related aortic re-intervention or sac shrinkage during a median follow-up of 24 months [12-48]. The secondary endpoint was every cause of vascular or cardiac morbidity and mortality. RESULTS The SBP value of 130 mmHg at the time of EVAR resulted, at ROC curve analysis, the most sensitive and specific for all the analyzed endpoints (T2E, n = 74; sac expansion n = 19; re-intervention, n = 10, sac shrinkage, n = 72). The combination antihypertensive therapy showed a significant inverse relationship with T2E occurrence. The incidence of primary endpoints was significantly higher (p < 0.001) in patients with SBP ≥ 130 mmHg. Cardiovascular death was significantly more prevalent (p < 0,001) in patients with SBP ≥130 mmHg. These findings were confirmed at the multivariable Cox regression analysis [primary endpoint HR = 0.09(0.06-0.15), p < 0.001; cardiovascular death HR = 0.33(0.12-0.85), p = 0.023]. CONCLUSIONS Tight SBP control at the target of 130 mmHg at the time of elective EVAR significantly decreases TE2 occurrence, need of re-intervention and cardiovascular death in a prolonged follow-up of a large sample of patients.
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Affiliation(s)
- Patrizia Lo Sapio
- Department of Surgery, Vascular and Endovascular Surgery Unit, Usl Toscana Centro, "San Giovanni di Dio" Hospital, Florence, Italy.
| | - Emiliano Chisci
- Department of Surgery, Vascular and Endovascular Surgery Unit, Usl Toscana Centro, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Anna Maria Gori
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Cristina Botteri
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Filippo Turini
- Department of Surgery, Vascular and Endovascular Surgery Unit, Usl Toscana Centro, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Stefano Michelagnoli
- Department of Surgery, Vascular and Endovascular Surgery Unit, Usl Toscana Centro, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Pre-emptive nonselective perigraft aortic sac embolization with coils to prevent type II endoleak after endovascular aneurysm repair. J Vasc Surg 2019; 69:1736-1746. [DOI: 10.1016/j.jvs.2018.10.054] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 10/01/2018] [Indexed: 11/21/2022]
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Katahashi K, Sano M, Takehara Y, Inuzuka K, Sugiyama M, Alley MT, Takeuchi H, Unno N. Flow dynamics of type II endoleaks can determine sac expansion after endovascular aneurysm repair using four-dimensional flow-sensitive magnetic resonance imaging analysis. J Vasc Surg 2019; 70:107-116.e1. [PMID: 30792053 DOI: 10.1016/j.jvs.2018.09.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 09/29/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the hemodynamic parameters of type II endoleaks (T2ELs) to predict sac expansion using four-dimensional flow-sensitive magnetic resonance imaging (4D-flow MRI) analysis. METHODS Patients who underwent endovascular aneurysm repair (EVAR) and were diagnosed with a T2EL were included in the study. Using 4D-flow MRI at 7 days, the peak flow velocity and amplitude of dynamics of blood flow per minute were measured in each T2EL vessel. The peak flow velocity was defined as the maximum of the absolute value of the blood flow velocity. The amplitude of dynamics of blood flow in the tributary arteries was defined as the sum of the absolute values of the inflow and outflow volume in each vessel. The amplitude of dynamics of blood flow in the tributary arteries per sac was calculated in each sac. The aneurysm sac diameter was measured by computed tomography (CT) at 1 year. The patients were divided into two groups according to the presence or absence of sac expansion. RESULTS Of 155 patients who underwent EVAR, both CT angiography and 4D-flow MRI were performed in 107 patients at 7 days after EVAR. Among them, 39 (36.4%) were found to have a T2EL, of whom 28 were re-evaluated with CT angiography and 4D-flow at 1 year; 7 patients had expanding sacs (expanding group), whereas 21 had nonexpanding sacs (not-expanding group). At 7 days, 28 patients had 80 T2EL vessels detected by 4D-flow MRI, of which 39 vessels (48.8%) had stopped flowing at 1 year (transient vessels); 41 vessels (51.3%) had sustained flow (persistent vessels). The persistent vessels had significantly larger peak flow velocity and amplitude of dynamics of blood flow. The comprehensive analysis of T2EL vessels per sac identified that the amplitude of dynamics of blood flow in the tributary arteries per sac was significantly higher in the expanding group than in the not-expanding group. A receiver operating characteristic curve analysis revealed that the sensitivity and specificity of sac enlargement at a cutoff value of 3750 mm3/min were 85.7% and 76.2%, respectively. CONCLUSIONS The fate of aneurysm sacs with T2ELs after EVAR has remained difficult to predict. A comprehensive analysis of concurrent multiple T2EL vessels using 4D-flow MRI analysis may enable prediction of the sac expansion after EVAR.
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Affiliation(s)
- Kazuto Katahashi
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masaki Sano
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yasuo Takehara
- Department of Fundamental Development for Advanced Low Invasive Diagnostic Imaging, Nagoya University, Graduate School of Medicine, Nagoya, Japan
| | - Kazunori Inuzuka
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masataka Sugiyama
- Department of Radiology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Marcus T Alley
- Department of Radiology, Stanford University, Palo Alto, Calif
| | - Hiroya Takeuchi
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoki Unno
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan; Department of Vascular Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan.
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Francois CJ, Skulborstad EP, Majdalany BS, Chandra A, Collins JD, Farsad K, Gerhard-Herman MD, Gornik HL, Kendi AT, Khaja MS, Lee MH, Sutphin PD, Kapoor BS, Kalva SP. ACR Appropriateness Criteria ® Abdominal Aortic Aneurysm: Interventional Planning and Follow-Up. J Am Coll Radiol 2018; 15:S2-S12. [DOI: 10.1016/j.jacr.2018.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 12/17/2022]
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Invited commentary. J Vasc Surg 2018; 67:173-174. [DOI: 10.1016/j.jvs.2017.06.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 06/30/2017] [Indexed: 11/20/2022]
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Natrella M, Rapellino A, Navarretta F, Iob G, Cristoferi M, Castagnola M, Lunardi G, Duc L, Fanelli G, Peruzzo Cornetto A, Meloni T, Peinetti F. Embo-EVAR: A Technique to Prevent Type II Endoleak? A Single-Center Experience. Ann Vasc Surg 2017; 44:119-127. [PMID: 28479464 DOI: 10.1016/j.avsg.2017.01.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/10/2016] [Accepted: 01/17/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intraprocedural aneurysm sac embolization (embo-EVAR) during endovascular abdominal aneurysm repair (EVAR) using coils and fibrin glue is a technique for preventing type II endoleak (EII). Our aim is to evaluate feasibility, safety and clinical outcome of this promising approach. MATERIALS AND METHODS A retrospective clinical case analysis of 72 patients who underwent EVAR during the period 2011-2014. Two groups were compared at 6 and 12 months follow-up with contrast media computed tomography scan and contrast-enhanced ultrasound (CEUS) imaging: consecutively, 36 patients (group A) treated with classic EVAR and 36 patients (group B) treated with embo-EVAR. Coils were released filling better as possible the aneurysm sac; the embolization was completed by injecting fibrin glue. Device and materials used, differential systemic and sac pressures, presence of any endoleak, and complication were registered. RESULTS In our experience, we had 100% technical success without surgical conversion. Embo-EVAR was performed, after endograft deployment, in group B patients, all with ratio of Δ-pressures (obtained from Δ-sac pressure/Δ-differential pressure) > 0.16. No early or late complications occurred and mortality was nil. Follow-up was performed with computed tomography-angiography and CEUS at 6 and 12 months. We observed 9 type II and 1 type Ia endoleak in group A and 2 type II and 1 type Ib endoleaks in group B. Mean radiation exposure time was 30.3 min in group A and 43.3 min in group B. EVAR procedure average cost was 9,000 €. The average cost of sac embolization was 1,500€. CONCLUSIONS Although a randomized study is necessary, embo-EVAR may be a valid approach to prevent type II endoleaks and further complications. Mild costs and exposure-dose increase could be accepted to avoid reinterventions, and in our experience, it could be routinely performed with excellent results.
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Affiliation(s)
| | | | | | - Gianluca Iob
- Department of Vascular Surgery, U. Parini Hospital, Aosta, Italy
| | - Massimo Cristoferi
- Department of Interventional Radiology, U. Parini Hospital, Aosta, Italy
| | | | - Gianmarco Lunardi
- Department of Interventional Radiology, U. Parini Hospital, Aosta, Italy
| | - Luca Duc
- Department of Interventional Radiology, U. Parini Hospital, Aosta, Italy
| | - Gianluca Fanelli
- Department of Interventional Radiology, U. Parini Hospital, Aosta, Italy
| | | | | | - Flavio Peinetti
- Department of Vascular Surgery, U. Parini Hospital, Aosta, Italy
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Systematic Review and Meta-Analysis of Preoperative Risk Factors of Type II Endoleaks after Endovascular Aneurysm Repair. Ann Vasc Surg 2017; 41:284-293. [DOI: 10.1016/j.avsg.2016.08.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 08/01/2016] [Accepted: 08/02/2016] [Indexed: 12/17/2022]
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Kaladji A, Daoudal A, Duménil A, Göksu C, Cardon A, Clochard E, Lucas A, Lalys F. Predictive Models of Complications after Endovascular Aortic Aneurysm Repair. Ann Vasc Surg 2016; 40:19-27. [PMID: 27903486 DOI: 10.1016/j.avsg.2016.08.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 06/30/2016] [Accepted: 08/04/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND The risk of long-term complications after endovascular aneurysm repair (EVAR) is still higher than open surgery and is a critical issue. This study aims to make available reliable statistical predictive models of complications after EVAR. METHODS Two hundred and thirteen patients who underwent EVAR between 2002 and 2012 were included in this study. The preoperative computed tomography scans were analyzed with a dedicated workstation to provide spatially correct 3-dimensional data. Age, gender, operation-related factors, and 21 morphologic variables were measured and included in the analyses. Five postoperative outcomes were studied. After an initial selection of predictors based on univariate analysis, binomial logistic regression models were proposed for each outcome. The ability to predict each outcome was assessed with receiver operating characteristic curves considering that an area under the curve (AUC) > 0.70 is generally considered sufficiently accurate. RESULTS The mean age was 74.8 ± 8.6 years with a mean follow-up of 43.8 ± 22.1 months. Respectively, rates and risk factors of each outcome were 25.3% (n = 51) for abdominal aortic aneurysm (AAA) enlargement (age, number of patent sac branches, iliac calcifications and tortuosity, aneurysmal thrombus), 7% (n = 15) for type IA endoleak (neck calcification and AAA diameter), 3.7% (n = 8) for type IB endoleak (iliac tortuosity, AAA diameter, neck thrombus), 19.8% (n = 40) for type II endoleak (female, number of patent sac branches), and 25.9% (n = 55) for reintervention from any cause (neck calcification). The risk associated to each outcome can be calculated with a combination of these different preoperative variables. AUC for each outcome were 79.6% for AAA enlargement, 70.4% for reintervention, 81.3% for type IA endoleak, 92.3% for type IB endoleak, 70.6% for type II endoleak. CONCLUSIONS This study shows that an exhaustive description of the preoperative anatomy before EVAR is a powerful and reliable tool to predict the risk of developing the most common complications after EVAR.
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Affiliation(s)
- Adrien Kaladji
- CHU Rennes, Department of Cardiothoracic and Vascular Surgery, Rennes, France; INSERM, U1099, Rennes, France; University Rennes 1, Signal and Image Processing Laboratory (LTSI), Rennes, France.
| | - Anne Daoudal
- CHU Rennes, Department of Cardiothoracic and Vascular Surgery, Rennes, France; INSERM, U1099, Rennes, France; University Rennes 1, Signal and Image Processing Laboratory (LTSI), Rennes, France
| | - Aurélien Duménil
- INSERM, U1099, Rennes, France; University Rennes 1, Signal and Image Processing Laboratory (LTSI), Rennes, France
| | | | - Alain Cardon
- CHU Rennes, Department of Cardiothoracic and Vascular Surgery, Rennes, France
| | - Elodie Clochard
- CHU Rennes, Department of Cardiothoracic and Vascular Surgery, Rennes, France
| | - Antoine Lucas
- CHU Rennes, Department of Cardiothoracic and Vascular Surgery, Rennes, France; INSERM, U1099, Rennes, France; University Rennes 1, Signal and Image Processing Laboratory (LTSI), Rennes, France
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Ferretto L, Irsara S. Totally Percutaneous Aneurysm Sac Embolization During Endovascular Aneurysm Repair. J Endovasc Ther 2016; 24:68-71. [PMID: 27733690 DOI: 10.1177/1526602816674212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To describe a sac embolization technique modification for type II endoleak prevention that makes a totally percutaneous approach feasible during endovascular aneurysm repair (EVAR) using the Excluder stent-graft. TECHNIQUE Percutaneous access of the common femoral arteries is obtained and 2 suture-mediated closure systems are placed on each side. A 16-F or 18-F sheath is placed for delivery of the Excluder stent-graft main body and a 16-F sheath is used on the contralateral side. After the stent-graft and contralateral limb component are delivered to their intended positions, a standard 0.035-inch hydrophilic guidewire is placed into the aneurysm sac through the same 16-F sheath. Then a 5-F, straight, 65-cm-long catheter is advanced over the standard wire into the sac in parallel with the contralateral limb. The contralateral limb is deployed, the standard guidewire is removed; coils are released through the 5-F catheter into the sac, followed by injection of 5 to 10 mL of double-component fibrin glue. CONCLUSION Totally percutaneous, nonselective sac embolization during EVAR, with a single access on each femoral artery, is feasible and helpful to physicians who wish to perform intraoperative sac embolization without relevant changes in their usual EVAR procedure.
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Affiliation(s)
- Luca Ferretto
- 1 Vascular and Endovascular Surgery Unit, Center for Vascular Medicine, ULSS 8 Asolo, Ospedale San Giacomo Apostolo, Castelfranco Veneto, Italy
| | - Sandro Irsara
- 1 Vascular and Endovascular Surgery Unit, Center for Vascular Medicine, ULSS 8 Asolo, Ospedale San Giacomo Apostolo, Castelfranco Veneto, Italy
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Barleben A, Inui T, Owens E, Lane JS, Bandyk DF. Intervention after endovascular aneurysm repair: Endosalvage techniques including perigraft arterial sac embolization and endograft relining. Semin Vasc Surg 2016; 29:41-49. [PMID: 27823589 DOI: 10.1053/j.semvascsurg.2016.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Endovascular aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysm (AAA). However, persistent AAA sac endoleak following EVAR can result in sac diameter increase requiring re-intervention in up to one-third of cases and even result in aneurysm rupture. In this case review, we summarize and detail endovascular re-interventions for each type of endoleak. We also detail specific options including stent-graft relining for indeterminate, Type III, and Type IV endoleaks and perigraft arterial sac embolization to induce thrombosis and resolve acute Type I, II, or III endoleaks. Endograft relining involves placement of a new stent-graft-elevating the bifurcation and extending the repair from renal artery to hypogastric arteries; perigraft arterial sac embolization involves placement of a catheter into the excluded sac from common femoral artery access, characterization of the inflow and outflow of the endoleak, and inducing cessation of the blood flow into the sac by the administration of thrombogenic material. Endoleaks range from low-pressure endoleaks, which can be safely monitored in a surveillance program to high-pressure endoleaks, which mandate intervention when associated with AAA sac diameter increase to protect from rupture. The evaluation of new devices and techniques to treat endoleak after EVAR remains an important issue in patient care after EVAR.
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Affiliation(s)
- Andrew Barleben
- Division of Vascular and Endovascular Surgery, Sulpizio Cardiovascular Center, University of California-San Diego School of Medicine, 9434 Medical Center Drive, Mail Code 7403, La Jolla, CA 92037; Department of Surgery, Division of Vascular Surgery, San Diego Veteran's Administration, La Jolla, CA.
| | - Tazo Inui
- Division of Vascular and Endovascular Surgery, Sulpizio Cardiovascular Center, University of California-San Diego School of Medicine, 9434 Medical Center Drive, Mail Code 7403, La Jolla, CA 92037; Department of Surgery, Division of Vascular Surgery, San Diego Veteran's Administration, La Jolla, CA
| | - Erik Owens
- Department of Surgery, Division of Vascular Surgery, San Diego Veteran's Administration, La Jolla, CA
| | - John S Lane
- Division of Vascular and Endovascular Surgery, Sulpizio Cardiovascular Center, University of California-San Diego School of Medicine, 9434 Medical Center Drive, Mail Code 7403, La Jolla, CA 92037; Department of Surgery, Division of Vascular Surgery, San Diego Veteran's Administration, La Jolla, CA
| | - Dennis F Bandyk
- Division of Vascular and Endovascular Surgery, Sulpizio Cardiovascular Center, University of California-San Diego School of Medicine, 9434 Medical Center Drive, Mail Code 7403, La Jolla, CA 92037; Department of Surgery, Division of Vascular Surgery, San Diego Veteran's Administration, La Jolla, CA
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Imaging-Based Predictors of Persistent Type II Endoleak After Endovascular Abdominal Aortic Aneurysm Repair. AJR Am J Roentgenol 2016; 206:1335-40. [DOI: 10.2214/ajr.15.15254] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Selective Intra-procedural AAA sac Embolization During EVAR Reduces the Rate of Type II Endoleak. Eur J Vasc Endovasc Surg 2016; 51:632-9. [DOI: 10.1016/j.ejvs.2015.12.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 12/13/2015] [Indexed: 11/18/2022]
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Piazza M, Squizzato F, Zavatta M, Menegolo M, Ricotta JJ, Lepidi S, Grego F, Antonello M. Outcomes of endovascular aneurysm repair with contemporary volume-dependent sac embolization in patients at risk for type II endoleak. J Vasc Surg 2015; 63:32-8. [PMID: 26432285 DOI: 10.1016/j.jvs.2015.08.049] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/02/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate outcomes of intraoperative aneurysm sac embolization during endovascular aneurysm repair (EVAR) in patients considered at risk for type II endoleak (EII), using a sac volume-dependent dose of fibrin glue and coils. METHODS Between January 2012 and December 2014, 126 patients underwent EVAR. Based on preoperative computed tomography evaluation of anatomic criteria, 107 patients (85%) were defined as at risk for EII and assigned to randomization for standard EVAR (group A; n = 55, 44%) or EVAR with intraoperative sac embolization (group B; n = 52, 42%); the remaining 19 patients (15%) were defined as at low risk for EII and excluded from the randomization (group C). Computed tomography scans were evaluated with OsiriX Pro 4.0 software to obtain aneurysm sac volume. Freedom from EII, freedom from EII-related reintervention, and aneurysm sac volume shrinkage at 6, 12, and 24 months were compared by Kaplan-Meier estimates. Patients in group C underwent the same follow-up protocol as groups A and B. RESULTS Patient characteristics, Society for Vascular Surgery comorbidity scores (0.99 ± 0.50 vs 0.95 ± 0.55; P = .70), and operative time (149 ± 50 minutes vs 157 ± 39 minutes; P = .63) were similar for groups A and B. Freedom from EII was significantly lower for group A compared with group B at 3 months (58% vs 80%; P = .002), 6 months (68% vs 85%; P = .04), and 12 months (70% vs 87%; P = .04) but not statistically significant at 24 months (85% vs 87%; P = .57). Freedom from EII-related reintervention at 24 months was significantly lower for group A compared with group B (82% vs 96%; P = .04). Patients in group B showed a significantly overall mean difference in aneurysm sac volume shrinkage compared with group A at 6 months (-11 ± 17 cm(3) vs -2 ± 14 cm(3); P < .01), 12 months (-18 ± 26 cm(3) vs -3 ± 32 cm(3); P = .02), and 24 months (-27 ± 25 cm(3) vs -5 ± 26 cm(3); P < .01). Patients in group C had the lowest EII rate compared with groups A and B (6 months, 5%; 12 months, 6%; 24 months, 0%) and no EII-related reintervention. CONCLUSIONS This randomized study confirms that sac embolization during EVAR, using a sac volume-dependent dose of fibrin glue and coils, is a valid method to significantly reduce EII and its complications during early and midterm follow-up in patients considered at risk. Although further confirmatory studies are needed, the faster aneurysm sac volume shrinkage over time in patients who underwent embolization compared with standard EVAR may be a positive aspect influencing the lower EII rate also during long-term follow-up.
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Affiliation(s)
- Michele Piazza
- Vascular and Endovascular Surgery Clinic, Padova University School of Medicine, Padova, Italy.
| | - Francesco Squizzato
- Vascular and Endovascular Surgery Clinic, Padova University School of Medicine, Padova, Italy
| | - Marco Zavatta
- Vascular and Endovascular Surgery Clinic, Padova University School of Medicine, Padova, Italy
| | - Mirko Menegolo
- Vascular and Endovascular Surgery Clinic, Padova University School of Medicine, Padova, Italy
| | | | - Sandro Lepidi
- Vascular and Endovascular Surgery Clinic, Padova University School of Medicine, Padova, Italy
| | - Franco Grego
- Vascular and Endovascular Surgery Clinic, Padova University School of Medicine, Padova, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Clinic, Padova University School of Medicine, Padova, Italy
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Chung R, Morgan RA. Type 2 Endoleaks Post-EVAR: Current Evidence for Rupture Risk, Intervention and Outcomes of Treatment. Cardiovasc Intervent Radiol 2014; 38:507-22. [PMID: 25189665 DOI: 10.1007/s00270-014-0987-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 07/26/2014] [Indexed: 10/24/2022]
Abstract
Type 2 endoleaks (EL2) are the most commonly encountered endoleaks following EVAR. Despite two decades of experience, there remains considerable variation in the management of EL2 with controversies ranging from if to treat, when to treat and how to treat. Here, we summarise the available evidence, describe the treatment techniques available and offer guidelines for management.
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Affiliation(s)
- Raymond Chung
- Radiology, Ground Floor, St. James Wing, St. George's Healthcare NHS Trust, Blackshaw Road, Tooting, London, SW17 0QT, England, UK,
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Inyección intraoperatoria de trombina como método de prevención de fugas tipo II en el tratamiento endovascular de los aneurismas de aorta abdominal. ANGIOLOGIA 2014. [DOI: 10.1016/j.angio.2014.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Sac Angiography and Glue Embolization in Emergency Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysm. Cardiovasc Intervent Radiol 2014; 38:457-62. [DOI: 10.1007/s00270-014-0873-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 01/25/2014] [Indexed: 11/26/2022]
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Quinones-Baldrich W, Levin ES, Lew W, Barleben A. Intraprocedural and postprocedural perigraft arterial sac embolization (PASE) for endoleak treatment. J Vasc Surg 2014; 59:538-41. [DOI: 10.1016/j.jvs.2013.07.104] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 07/21/2013] [Accepted: 07/23/2013] [Indexed: 11/30/2022]
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Alerci M, Giamboni A, Wyttenbach R, Porretta AP, Antonucci F, Bogen M, Toderi M, Guerra A, Sartori F, Tutta P, Inglese L, Limoni C, Gallino A, Von Segesser LK. Endovascular Abdominal Aneurysm Repair and Impact of Systematic Preoperative Embolization of Collateral Arteries: Endoleak Analysis and Long-term Follow-up. J Endovasc Ther 2013; 20:663-71. [DOI: 10.1583/12-4188mr.1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
BACKGROUND Fibrin sealants are used for hemostasis and tissue adherence. AIM OF STUDY This systematic review summarizes published clinical data for fibrin sealant use in cardiovascular surgery. METHODS A literature search for the following terms was conducted using PubMed and EMBASE: (TISSEEL or Tissucol or Beriplast P or Evicel or Quixil or Crosseal or Reliseal or Fibringluraas or Bolheal or Tachosil or Vivostat or Vitagel or Artiss or "fibrin glue" or "fibrin sealant" or "fibrin tissue adhesive") and (cardiac or cardiovascular or vascular or heart or coronary or surgery). Case reports and series were excluded; although reports of controlled trials were preferred, uncontrolled trial data were also considered. RESULTS Clinical trials and chart review analyses of fibrin sealants were identified and summarized. Although clinical trial data were available for other agents, the majority of published studies examined TISSEEL. Overall, TISSEEL and other fibrin sealants showed improvements over standard of care or control groups for a variety of predefined endpoints. Safety findings are also summarized. CONCLUSIONS Data from these studies showed that fibrin sealants were well tolerated and provided effective hemostasis in a range of cardiac and aortic surgeries.
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Affiliation(s)
- John A Rousou
- Division of Cardiac Surgery, Baystate Medical Center, Springfield, Massachusetts 01107, USA.
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Piazza M, Frigatti P, Scrivere P, Bonvini S, Noventa F, Ricotta JJ, Grego F, Antonello M. Role of aneurysm sac embolization during endovascular aneurysm repair in the prevention of type II endoleak-related complications. J Vasc Surg 2013; 57:934-41. [DOI: 10.1016/j.jvs.2012.10.078] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Revised: 10/02/2012] [Accepted: 10/06/2012] [Indexed: 10/27/2022]
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Coutu JM, Fatimi A, Berrahmoune S, Soulez G, Lerouge S. A new radiopaque embolizing agent for the treatment of endoleaks after endovascular repair: Influence of contrast agent on chitosan thermogel properties. J Biomed Mater Res B Appl Biomater 2012; 101:153-61. [DOI: 10.1002/jbm.b.32828] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 06/26/2012] [Accepted: 08/20/2012] [Indexed: 11/08/2022]
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41
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Ronsivalle S. Regarding "outcomes of percutaneous endovascular intervention for type II endoleak with aneurysm expansion". J Vasc Surg 2012; 56:1198. [PMID: 23026431 DOI: 10.1016/j.jvs.2012.06.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 05/23/2012] [Accepted: 06/01/2012] [Indexed: 11/17/2022]
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Karthikesalingam A, Thrumurthy SG, Jackson D, Choke E, Sayers RD, Loftus IM, Thompson MM, Holt PJ. Current Evidence Is Insufficient to Define an Optimal Threshold for Intervention in Isolated Type II Endoleak After Endovascular Aneurysm Repair. J Endovasc Ther 2012; 19:200-8. [DOI: 10.1583/11-3762r.1] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Gallagher KA, Ravin RA, Meltzer AJ, Khan MA, Coleman DM, Graham AR, Aiello F, Shrikhande G, Connolly PH, Dayal R, Karwowski JK. Midterm Outcomes After Treatment of Type II Endoleaks Associated With Aneurysm Sac Expansion. J Endovasc Ther 2012; 19:182-92. [DOI: 10.1583/11-3653.1] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Mukherjee D, Waked TM. A case of hybrid repair of ruptured abdominal aortic aneurysm with use of thrombin for acute treatment of type II endoleak. Vascular 2012; 20:42-5. [PMID: 22328619 DOI: 10.1258/vasc.2011.cr0277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Endovascular repair for ruptured abdominal aortic aneurysm has demonstrated superior results when compared with open repair and will likely become the standard of care when the anatomy of the aneurysm is appropriate for endovascular repair.
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Ronsivalle S, Faresin F, Franz F, Rettore C, Zanchetta M, Olivieri A. Type II Endoleak:From Treatment of a Complication to Prevention. J Endovasc Ther 2012; 19:128-9. [DOI: 10.1583/11-3691l.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Ronsivalle S, Faresin F, Franz F, Rettore C, Zanchetta M, Zonta L. Funnel Technique for EVAR: “A Way Out” for Abdominal Aortic Aneurisms With Ectatic Proximal Necks. Ann Vasc Surg 2012; 26:141-8. [DOI: 10.1016/j.avsg.2011.03.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Revised: 02/26/2011] [Accepted: 03/02/2011] [Indexed: 12/20/2022]
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Lu Q, Feng J, Yang Y, Nie B, Bao J, Zhao Z, Feng X, Pei Y, Yuan L, Mei Z, Feng R, Jing Z. Treatment of Type I Endoleak After Endovascular Repair of Infrarenal Abdominal Aortic Aneurysm: Success of Fibrin Glue Sac Embolization. J Endovasc Ther 2010; 17:687-93. [DOI: 10.1583/10-3084.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Jonker FHW, Aruny J, Moll FL, Muhs BE. Commentary: reduction of type II endoleak using embolization of the aneurysm sac during EVAR. J Endovasc Ther 2010; 17:525-6. [PMID: 20681770 DOI: 10.1583/09-3004c.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Frederik H W Jonker
- Sections of Vascular Surgery and Interventional Radiology, Yale University School of Medicine, New Haven, Connecticut, USA.
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