Chronological Change of the Sac after Endovascular Aneurysm Repair

Correlation Between Calcium Scoring and Abdominal Aortic Aneurysm Endovascular Repair Outcomes

OBJECTIVES

Endovascular aneurysm repair, though minimally invasive and has the benefit of relatively low perioperative complication rates, it is associated with significant long term reintervention rates related to endoleaks. Several variables have been studied to predict the outcomes of endovascular aneurysm repair, 1 of which is the calcium burden of the vasculature. This prompted us to study the association between calcium burden measured by the standardized Agatston scoring system and the outcomes of Endovascular aneurysm repair.

METHODS

This is a retrospective study of patients who underwent Endovascular aneurysm repair from 2008 to 2020 at our institution and who had a non-contrast computerized tomography scan preoperatively, accounting for 87 patients. The calcium burden of the vasculature was measured by the Agatston scoring system allowing for better reproducibility, and the outcome variables included mortality and endoleaks.

RESULTS

Patients with higher median total calcium scores (≥12966.9) had significantly lesser survival (79.8% vs 52.3% (P = .002) at five years compared to patients with lower median total calcium score (<12966.9). Also, patients with type 2 endoleaks had higher calcium scores in above the aneurysm level ((1591.2 vs 688.2), P = .05)) compared to patients with no type 2 endoleaks.

CONCLUSION

Calcium score assigned using a standardized Agatston scoring system can be used as a predictor of mortality risk assisting in deciding the treatment of choice for patients.

Midterm outcomes of physician-modified endovascular stent grafts for the treatment of complex abdominal aortic aneurysms in Korea: a retrospective study

Purpose

Physician-modified endovascular stent grafts (PMEG) are a good treatment option for complex abdominal aortic aneurysms (AAAs), especially in high-risk patients not amenable to open repair, and when commercial fenestrated devices are not available. We report our single-center experience with PMEG for the treatment of complex AAAs.

Methods

We retrospectively reviewed patients who underwent PMEG repair for AAA from November 2016 to September 2020 at our institution. Demographic data, anatomic characteristics, perioperative and postoperative outcomes, major adverse events, and 30-day mortality were analyzed.

Results

We identified 12 patients who underwent PMEG for complex AAA. The mean age was 74 years and the mean maximal AAA diameter was 58.1 mm. Indications for treatment included 4 impending or contained ruptures, 2 mycotic aneurysms, and 6 symptomatic cases. The technical success rate was 91.7%. Aneurysm sac regression was observed in 7 patients (58.3%), including 2 cases of complete regression. There was 1 aneurysm-related mortality at 3 months due to mycotic aneurysm. Also, there was 1 postoperative complication case of transient renal failure requiring temporary dialysis. At 1 year, there was 1 branch occlusion from the initial failed cannulation case and 2 type 1A endoleaks, and there was 1 case of open explantation.

Conclusion

PMEG showed a low technical failure rate and acceptable midterm stent durability and sac stability, comparable to conventional endovascular aneurysm repair. Despite the small number of cases, there was a tendency for a high sac regression rate, although longer follow-up is needed.

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.

Editor's Choice - Systematic Review and Meta-Analysis of the Outcome of Treatment for Type II Endoleak Following Endovascular Aneurysm Repair

OBJECTIVES

The efficacy and need for secondary interventions for type II endoleaks following endovascular abdominal aortic aneurysm repair (EVAR) remain controversial. This systematic review aimed at investigating the clinical outcomes of different type II endoleak treatments in patients with a persistent type II endoleak after EVAR.

DATA SOURCES

Embase, Medline via Ovid, Web of Science Core Collection, the Cochrane CENTRAL, and Google Scholar.

REVIEW METHODS

This systematic review was performed in accordance with the PRISMA Statement. Outcomes of interest were technical and clinical success, change in sac diameter, complications, need for additional interventions, abdominal aortic aneurysm (AAA) rupture, and (AAA related) mortality. Meta-analyses were performed with random effects models.

RESULTS

A total of 59 studies were included, with a cumulative cohort of 1073 patients with persistent type II endoleak. Peri-operative complications following treatment of type II endoleaks occurred in 3.8% of patients (95% CI 2.7-5.2%), and AAA related mortality was 1.8% (95% CI 1.1-2.7%). Overall technical success was 87.9% (95% CI 83.1-92.1%), while clinical success was 68.4% (95% CI 61.2-75.1%). Among studies detailing sac dynamics, decrease or stable sac, with or without resolution, was achieved in 78.4% (95% CI 70.2-85.6%). Changes in sac diameter following type II endoleak treatment were documented in 157 patients to at least 24 months. Within this group an actual decrease in sac diameter was reported in only 27 of 40 patients.

CONCLUSION

There is little evidence supporting the efficacy of secondary intervention for type II endoleaks after EVAR. Although generally safe, the lack of evidence supporting the efficacy of type II endoleak treatment leads to difficulty in assessing its merits.

Circulating biomarkers are not associated with endoleaks after endovascular repair of abdominal aortic aneurysms

OBJECTIVE

Endoleak is a common complication of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) but can be detected only through prolonged follow-up with repeated aortic imaging. This study examined the potential for circulating matrix metalloproteinase 9 (MMP9), osteoprotegerin (OPG), D-dimer, homocysteine (HCY), and C-reactive protein (CRP) to act as diagnostic markers for endoleak in AAA patients undergoing elective EVAR.

METHODS

Linear mixed-effects models were constructed to assess differences in AAA diameter after EVAR between groups of patients who did and did not develop endoleak during follow-up, adjusting for potential confounders. Circulating MMP9, OPG, D-dimer, HCY, and CRP concentrations were measured in preoperative and postoperative plasma samples. The association of these markers with endoleak diagnosis was assessed using linear mixed effects adjusted as before. The potential for each marker to diagnose endoleak was assessed using receiver operating characteristic curves.

RESULTS

Seventy-five patients were included in the study, 24 of whom developed an endoleak during follow-up. Patients with an endoleak had significantly larger AAA sac diameters than those who did not have an endoleak. None of the assessed markers showed a significant association with endoleak. This was confirmed through receiver operating characteristic curve analyses indicating poor diagnostic ability for all markers.

CONCLUSIONS

Circulating concentrations of MMP9, OPG, D-dimer, HCY, and CRP were not associated with endoleak in patients undergoing EVAR in this study.