The Influence of Unfavorable Aortoiliac Anatomy on Short-Term Outcomes after Endovascular Aortic Repair

A systematic review on anatomical predictors of abdominal aortic aneurysm remodeling after endovascular repair

OBJECTIVE

Long-term outcomes after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) are inferior to open surgical repair with regard to reinterventions and late mortality. AAA sac remodeling after EVAR has been associated with endoleaks, reinterventions, and mortality. Therefore, predictors of AAA sac remodeling could indirectly give insight into long-term EVAR outcomes. This review aims to provide an overview of the evidence on anatomical predictors of positive and negative AAA sac remodeling after EVAR.

METHODS

A systematic literature review and analysis were conducted according to the PRISMA and Cochrane guidelines. PubMed and Scopus databases were searched using terms of AAA sac growth, shrinkage, and remodeling. Eligible articles were identified and only papers that included currently used endografts were included.

RESULTS

Nineteen studies that reported on a total of 27 anatomical parameters of the aortoiliac anatomy were included. Only 4 parameters were investigated by >5 studies, 7 parameters were investigated by 3-5 studies, 6 parameters were investigated by 2 studies, and 10 parameters were investigated by 1 study. For the presence of neck thrombus, 3 out of 4 studies reported similar results indicating that it may predict less AAA sac shrinkage. AAA thrombus, total AAA volume, flow-lumen volume, and the number of hostile neck parameters were only investigated by 2-3 studies, but they seem promising in predicting sac remodeling. For hostile neck anatomy, neck length, infrarenal neck angulation, and patency of the inferior mesenteric artery, no significant association with any category of AAA sac remodeling was found.

CONCLUSIONS

This review presents neck thrombus, AAA thrombus, number of hostile neck parameters, total AAA volume, and AAA flow-lumen volume as important anatomical features that are likely to play a role in AAA remodeling after endovascular repair that should be further explored using advanced imaging techniques. This review also showed that strong consistent evidence on anatomical predictors of AAA sac remodeling after EVAR is lacking. Therefore, further research with large patient groups on a broad range of predictors of AAA sac change after EVAR is needed to complement the current gap in the evidence.

Clinical Outcomes of Surgical Repair with a Composite Graft for Abdominal Aortic Aneurysm Accompanied by Iliac Artery Aneurysm

Background

Iliac artery aneurysm is frequently found in patients undergoing surgical repair of an abdominal aortic aneurysm. The use of commercial bifurcated grafts is insufficient for aorto-biiliac replacement with complete iliac artery aneurysm resection. We evaluated the effectiveness of handmade composite grafts for this purpose.

Methods

A total of 233 patients underwent open surgery for abdominal aortic aneurysm between 2003 and 2019, including 155 patients (67%) treated with commercial grafts and 78 patients (33%) treated with handmade composite grafts. Their operative characteristics, postoperative outcomes, and late outcomes were retrospectively reviewed.

Results

The early mortality rate did not differ significantly between the groups. On average, the handmade composite graft technique took approximately 15 minutes longer than the commercial graft technique (p=0.037). Among patients who underwent elective surgery, no significant differences between the conventional and composite groups were observed in the major outcomes, including red blood cell transfusion volume (2.8±4.7 units vs. 3.1±4.7 units, respectively; p=0.680), reoperation for bleeding (2.7% vs. 3.1%, respectively; p>0.999), bowel ischemia (0% vs. 1.6%, respectively; p=0.364), and intensive care unit stay duration (1.9±6.6 days vs. 1.6±2.4 days, respectively; p=0.680). The incidence of target vessel occlusion also did not differ significantly between groups.

Conclusion

The increased technical demand involved with handmade composite grafting did not negatively impact the outcomes. This technique may be a viable option because it overcomes problems associated with commercial grafts.