Editor's Choice - Endovascular Aneurysm Repair in High Risk Patients: A Systematic Review and Meta-Analysis.

OBJECTIVE: To investigate outcomes of endovascular aneurysm repair (EVAR) in high risk patients. METHODS: Bibliographic sources (MEDLINE, EMBASE, CINAHL, and CENTRAL) were searched using combinations of thesaurus and free text terms. The review protocol was registered in PROSPERO (CRD42021287207) and reported according to PRISMA 2020. Pooled estimates were calculated using odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI) applying the Mantel-Haenszel or inverse variance method. EVAR peri-operative mortality in high risk patients over time was examined with mixed effects meta-regression. The GRADE framework was used to rate the certainty of evidence. RESULTS: The pooled peri-operative mortality in 18 416 high risk patients who underwent EVAR was 3% (95% CI 2.3 - 4%) and has significantly reduced over time (year of publication p = .003; median study point p = .023). The peri-operative mortality was significantly lower in high risk patients treated with EVAR compared with open repair (OR 0.64; 95% CI 0.45 - 0.92), but no significant difference was found in overall (HR 1.06; 95% CI 0.76 - 1.49) or aneurysm related mortality (HR 0.57; 95% CI 0.21 - 1.55). No significant difference was found in overall mortality between high risk patients treated with EVAR vs. no intervention (HR 0.42; 95% CI 0.14 - 1.26), but the aneurysm related mortality was significantly lower in the former (HR 0.30; 95% CI 0.14 - 0.63). The peri-operative mortality was higher in high risk than normal risk patients treated with EVAR (OR 2.33; 95% CI 1.75 - 3.10), as was the overall mortality (HR 3.50; 95% CI 2.55 - 4.80). The certainty of evidence was very low for EVAR vs. open surgery or no intervention and low for high vs. normal risk patients. CONCLUSION: The EVAR peri-operative mortality in high risk patients has improved over time. Even though the aneurysm related mortality of EVAR is lower compared with no intervention, EVAR may confer no overall survival benefit.

Factors associated with elimination of type II endoleak during the first year after endovascular aneurysm repair.

OBJECTIVE: The natural history of endoleak type II (ET II) after endovascular aneurysm repair (EVAR) is still debatable. The aim of this study was to examine the presence of preoperative and postoperative factors associated with persistence of ET II during the initial 12-month follow-up period. METHODS: A two-center retrospective study including patients subjected to EVAR from 2006 to 2017 was undertaken. Patients with ET II at 1-month computed tomography angiography (CTA) were categorized into two groups, resolution (group 1) vs persistence (group 2) of ET II at 12-month CTA. Preoperative demographics, comorbidities, aneurysm anatomic details, and pelvic artery index were assessed. Intraoperative details were also recorded. RESULTS: Of 825 patients, 140 (17%) patients (mean age, 71.7 ± 8.5 years; 94% male) presented with ET II at 1-month CTA. Group 1 included 58 patients (41%) and group 2, 82 patients (59%). The anatomic characteristics of the inferior mesenteric artery and lumbar arteries and the pelvic artery indices were not associated with ET II persistence. All patients in group 1 had presence of intraluminal thrombus (ILT) on preoperative CTA (group 1, 100%; group 2, 67%; P = .001), and the circular pattern of ILT was more common in group 1 (group 1, 44%; group 2, 24%; P = .01). At 12-month CTA, the mean sac regression was higher in group 1 (group 1, -3 ± 4 mm; group 2, 0.55 ± 3 mm; P = .000). After multivariate analysis, persistence of ET II was directly associated only with intraoperative internal iliac occlusion (odds ratio [OR], 0.232; 95% confidence interval [CI], 0.06-0.86; P = .03) and inversely with statin therapy (OR, 2.6; 95% CI, 1.01- 6.8; P = .047) and sac regression (OR, 1.24; 95% CI, 1.11-1.39; P = .001). CONCLUSIONS: Induced occlusion of the internal iliac artery during EVAR was the only factor associated with persistence of ET II during the first year after EVAR. The presence and pattern of ILT may play a role in ET II persistence, whereas the number of patent infrarenal aortic branches and their diameter as well as the pelvic artery indices were not associated with ET II. The use of statins may have a positive effect on ET II resolution during the first postoperative year. Sac diameter is more likely to regress in patients with ET II resolution.

Anatomical Differences Between Intact and Ruptured Large Abdominal Aortic Aneurysms.

Purpose: To compare different anatomical characteristics between intact and ruptured large abdominal aortic aneurysms (rAAA >80 mm) with the goal of refining the process of estimating rupture risk. Materials and Methods: A retrospective study involving 62 male patients with large (>80 mm) aneurysms matched for age and smoking produced a 31-patient elective group with a mean maximum aneurysm diameter of 92±9.7 mm and a 31-patient rAAA group (mean maximum aneurysm diameter 95.7±12 mm). Preoperative computed tomography angiography scans were analyzed with a dedicated workstation, and anatomical characteristics of the aortic neck, iliac arteries, and aneurysm were compared in multivariable regression analyses; the outcomes are given as the odds ratio (OR) with 95% confidence interval (CI). The prognostic utility of several characteristics as predictors of rupture occurrence was examined with receiver operating characteristic (ROC) curves. Results: Anatomical characteristics differing significantly between elective and ruptured aneurysms were the infrarenal aortic neck diameters at 5 mm, 10 mm and 15 mm; the neck length and calcification; the common iliac artery (CIA) lengths; the iliac artery indexes; the left CIA and external iliac artery diameters; and the total and true lumen aneurysm volumes. Intraluminal thrombus (ILT) volume did not differ (p=0.76), although its distribution in elective vs ruptured cases did [absent: 0% vs 19%, respectively (p=0.025); circumferential: 61% vs 35%, respectively (p=0.04)]. Total aneurysm volume was higher in rAAA (442±140 mL) vs intact AAA (331±143 mL, p=0.014), while the ILT/total aneurysm volume rate was lower in rAAA (55%) vs intact AAA (70%, p=0.02). Multivariate analysis determined that a shorter left CIA (OR 1.07, 95% CI 1.01 to 1.1, p=0.016) and a smaller total aneurysm volume (OR 1.007, CI. 1.001 to 1.014, p=0.016) were associated with intact AAA. After a ROC curve analysis, left CIA length <50 mm demonstrated a lower incidence of rupture (sensitivity 60% and specificity 78%), while total aneurysm volume <380 mL had 60% sensitivity and specificity. Conclusion: Large rAAAs seem to have different anatomical characteristics than similarly sized intact AAAs. Large intact AAAs have lower total aneurysm volumes and shorter left CIAs, with higher ILT/aneurysm volume rates.

Systematic Review and Meta-Analysis of Outcomes of Open and Endovascular Repair of Ruptured Abdominal Aortic Aneurysm in Patients with Hostile vs. Friendly Aortic Anatomy.

OBJECTIVE: To investigate the effect of hostile aortic anatomy on the outcomes of endovascular and open repair for ruptured abdominal aortic aneurysm (AAA). METHODS: Electronic bibliographic sources (MEDLINE, EMBASE, CENTRAL) were searched using a combination of thesaurus and free text terms to identify studies comparing treatment outcomes of ruptured AAA in patients with hostile vs. friendly aortic anatomy. A systematic review was conducted that conformed to the PRISMA guidelines using a registered protocol (CRD42019127307). The primary outcomes were peri-operative mortality, freedom from aneurysm related mortality, and overall survival. Pooled estimates of dichotomous outcomes were calculated using odds ratio (OR) and 95% confidence interval (CI). A time to event data meta-analysis was conducted using the inverse variance method and the results were reported as summary hazard ratio (HR) and associated 95% CI. Subgroup analysis for type of treatment (endovascular aneurysm repair [EVAR] or open repair) was undertaken. Random effects models of meta-analysis were developed. RESULTS: Ten observational studies were included reporting a total of 1284 patients (748 with hostile anatomy and 536 with friendly anatomy). Patients with hostile anatomy had a higher peri-operative mortality than patients with friendly anatomy (OR 1.73, 95% CI 1.13-2.66; p = .01). Subgroup analysis showed a significant difference in peri-operative mortality in favour of friendly anatomy in patients treated by EVAR (OR 1.76, 95% CI 1.01-3.08; p = .05), but not in those treated by open repair (OR 1.37, 95% CI 0.83-2.27; p = .22). Patients with hostile anatomy treated by EVAR had a significantly higher hazard of death in follow up than patients with friendly aortic anatomy (HR 2.01, 95% CI 1.18-3.44, p = .01), whereas for open surgical repair, the survival was similar in patients with hostile and those with friendly aortic anatomy (HR 0.90, 95% CI 0.61-1.32, p = .58). CONCLUSION: Hostile aortic anatomy is associated with increased mortality in patients with ruptured AAA treated by EVAR.

Completion imaging techniques and their clinical role after carotid endarterectomy: Systematic review of the literature.

BACKGROUND: Completion imaging has been suggested for the intraoperative quality control assessment of the carotid endarterectomy technical success, in order to immediately resolve pathologic findings and accordingly improve patients' outcome. The aim of this study was to present existing evidence of different completion imaging techniques after carotid endarterectomy and their role on clinical outcome. MATERIAL AND METHODS: A systematic review was performed searching in MEDLINE, CENTRAL, and Cochrane databases including studies reporting on completion imaging techniques after carotid endarterectomy. RESULTS: A total of 12,378 patients in 35 studies (20 retrospective and 15 prospective) underwent a completion imaging technique after carotid endarterectomy: in 19 studies, 5340 patients underwent arteriography; in 5 studies, 2095 angioscopy; in 21 studies, 5722 DUS; and in 2 studies, 150 patients underwent transcranial Doppler. Ten studies assessed > 1 imaging technique. The mean age was 67 ± 7 years old (69% males) with common co-morbidities to be hypertension (74%), smoking (64%), and hyperlipidemia (54%). Almost half of the patients (4949; 44%) were treated for symptomatic disease. In 1104 (9.7%) patients, a major defect was identified intra-operatively, while in 329 patients (2.9%), a minor defect. Common pathological findings were the presence of mural thrombus, carotid dissection, residual stenosis, and intimal flaps. An immediate re-intervention was undertaken in 75% (790/1053) of the patients to treat a major intra-operative imaging finding. In patients with re-intervention, only 2.3% (14/609) had an intra-operative stroke and 0.8% (5/609), a transient ischemic attack, while only 1.4% (8/575) had a stroke and 0.2% a transient ischemic attack (1/575) during 30-day post-operative period. No intra-operative death was reported. In the same period, the restenosis rate of internal and common carotid artery was 0.5% (3/575) and 0.2% (1/575), respectively. CONCLUSION: Completion imaging techniques can detect defects in almost 10% of patients that may lead to immediate intra-operative surgical revision with low intra-operative stroke/transient ischemic attack rate and low early carotid restenosis. During the 30-day follow-up period, in those patients, the incidence of stroke/transient ischemic attack may be low but present. This review cannot provide any evidence on which completion imaging technique is better, and the clinical impact conferred by each technique in the absence of a randomized control studies.

Meta-analysis of the accuracy of contrast-enhanced ultrasound for the detection of endoleak after endovascular aneurysm repair.

OBJECTIVE: The purpose of this systematic review and meta-analysis was to investigate the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) for detection of endoleak after endovascular aneurysm repair (EVAR). METHODS: We searched electronic bibliographic databases for original articles comparing concurrent CEUS and computed tomography angiography for detection of endoleak after EVAR. We assessed the methodologic quality of the studies with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We constructed 2 × 2 contingency tables for all selected studies including true-positive, false-positive, false-negative, and true-negative results for all endoleaks and for type I and type III endoleaks. We used a mixed-effects logistic regression model to estimate summary sensitivity and specificity. We developed hierarchical summary receiver operating characteristic curves and calculated the area under the curve (AUC). RESULTS: We identified 26 studies reporting a total of 2638 paired scans in 2217 patients. The major risk of bias of the selected studies pertained to blinding for the index test and the reference standard. The pooled sensitivity and specificity of CEUS for all endoleaks were 0.94 (95% confidence interval [CI], 0.89-0.97) and 0.93 (95% CI, 0.89-0.96), respectively. The AUC was 0.98 (95% CI, 0.93-0.99). The summary estimate of sensitivity and specificity for type I and type III endoleaks was 0.97 (95% CI, 0.8-1.00) and 1.00 (95% CI, 0.99-1.00), respectively. The AUC was 1.00 (95% CI, 0.99-1.00). CONCLUSIONS: CEUS has a high sensitivity and specificity in the detection of endoleaks after EVAR. CEUS is a useful tool in EVAR surveillance.

Suprarenal Aortic Remodeling after Endovascular Aortic Aneurysm Repair among Three Endografts with Different Types of Proximal Fixation System.

BACKGROUND: Remodeling of suprarenal aorta after endovascular aortic aneurysm repair (EVAR) in relation to different endograft designs has not been thoroughly investigated. The aim of this study is to assess the anatomical configuration of the suprarenal aorta after using endografts with different proximal fixation during the first post-EVAR year. METHODS: A retrospective study including EVAR patients using 3 types of endografts with different proximal fixation systems according to Instructions for Use was undertaken (50: Ovation, Endologix, Irvin, CA; 25: Endurant IIs, Medtronic, Santa Rosa, CA; 25: Excluder C3, W. L. Gore & Associates, Flagstaff, AZ). Comorbidities were recorded. Anatomic variables of the supra-aortic anatomy, abdominal aortic aneurysm (AAA) maximum diameter, and neck angulation were analyzed. Computed tomography angiography was obtained preoperatively at 1 and 12 months post-EVAR, while a duplex scan was undertaken at 6 months. RESULTS: Comorbidities were not different across the 3 groups. Presence and amount of neck calcification (P = 0.139) and thrombus (P = 0.116) was similar among groups. Maximum aortic diameter showed significant reduction from preoperative measurements to 12-month postoperative ones, for all groups. (Ovation: 56.5 to 53 mm, P < 0.001; Endurant: 57 to 51 mm, P < 0.001; Excluder: 55 to 50 mm, P < 0.001). Suprarenal angulation was decreased significantly in the Ovation (P < 0.001) and Excluder groups (P = 0.05), while the infrarenal angulation was decreased in all groups. Among endografts, the decrease in AAA maximum diameter was similar (P = 0.99), while the suprarenal aortic diameter was significantly increased in Ovation patients in comparison to the other 2 endografts at the level of 5 mm (P = 0.02) and 25 mm (P = 0.01). Suprarenal angulation reduction was similar (P = 0.7), while infrarenal angulation was significantly more decreased in Ovation endograft than the other 2 systems (P < 0.001). CONCLUSIONS: Proximal endograft configuration appears to have different impact on supra-aortic anatomy. Longer follow-up is needed to clarify future remodeling and clinical impact of these observations.

Intentional Targeted False Lumen Occlusion after Aortic Dissection: A Systematic Review of the Literature.

BACKGROUND: Residual patent false lumen (FL) after chronic type B aortic dissection (cTBAD) or type A aortic dissection (TAAD) treatment is independently associated with poor long-term outcomes. The aim of our study was to present endovascular techniques and the existing experience with targeted FL thrombosis after cTBAD or TAAD treatment. MATERIAL AND METHODS: A systematic review was performed (Preferred Reporting Items for Systematic reviews and Meta-Analyses) searching in MEDLINE, CENTRAL, and Cochrane databases for studies reporting on targeted FL occlusion after cTBAD or TAAD treatment. RESULTS: One hundred one patients either after open repair of a TAAD (n = 40; 3 case reports and 3 retrospective studies) or after cTBAD (n = 61; 13 case reports and 6 retrospective studies) underwent an endovascular procedure for intentional FL occlusion (2 studies reported on both procedures). Among TAAD patients, 27 of 40 (68%) had previous open repair, whereas 48 of 61 (79%) with cTBAD had a previous endovascular repair. Thirty-one (78%) patients with TAAD and fifty-one (83%) with cTBAD were treated electively. Four main techniques were used: (1) the candy-plug (19/101), (2) the knickerbocker (3/91), (3) the "cork in the bottle neck" technique (2/101), and (4) FL embolization with combined use of coils, onyx, plugs, and glue (77/101). The technical success rate was 100%, with a 30-day mortality rate of 2.5% (1/40) in TAAD and 0% in cTBAD patients. During follow-up (ranging: 2 to 63 months), the mortality rate was 0% (0/31) and 7.1% (4/61) in TAAD and cTBAD patients, respectively. The FL remained completely thrombosed in 78% (31/40) of TAAD and 62% (38/61) of cTBAD patients, whereas it was partially thrombosed in 3 and 2 patients, respectively (no report for 22 patients). CONCLUSIONS: Intentional FL occlusion seems to be a feasible less invasive approach after cTBAD or TAAD treatment, which is not broadly used. Future larger studies with longer follow-up duration may demonstrate the apparent benefit in terms of aortic remodeling or stabilization of the disease progression.

Carotid artery plaque echomorphology and its association with histopathologic characteristics.

OBJECTIVE: The aim of the study was to determine the association of ultrasonic texture features (severity of stenosis, grey scale median, plaque area, juxtaluminal black area [JBA], and discrete white areas) previously shown to be independent predictors for stroke with established histologic features of plaque instability. METHODS: A cross-sectional study was performed involving 70 patients scheduled for carotid endarterectomy. Before surgery, carotid plaque texture features were obtained with ultrasound after normalization using commercially available software (LifeQ Medical, Nicosia, Cyprus). After carotid endarterectomy, histologic features (number of macrophages [CD68 staining], severity of angiogenesis [CD31 staining], smooth muscle cell [SMC] numbers, size of lipid core, thickness of the fibrous cap, presence of intraplaque hemorrhage, plaque rupture, and instability) also were studied. RESULTS: Symptomatic (n = 20) and asymptomatic (n = 50) patients were comparable in terms of internal carotid stenosis (mean stenosis, 86%; range, 60%-99%) and prevalence of risk factors except for total cholesterol (which was higher in the symptomatic group; P = .023). A low grey scale median and the presence of discrete white areas were associated with an increased number of macrophages (P < .001 and P < .001, respectively), increased neovascularization (P = .019 and P < .001, respectively), larger lipid core (P = .001 and P = .025, respectively), intraplaque hemorrhage presence (P = .001 and P = .001, respectively), plaque rupture (P = .001 and P = .025, respectively), and a decreased number of SMCs (P = .003 and P = .003, respectively). The presence of JBA was associated with a decreased number of SMCs (P = .042), larger lipid core (P = .013), and plaque rupture (P = .002). The combination of a thin fibrous cap with either a large lipid core or plaque rupture was associated with the highest (65%) prevalence of a JBA. Plaque area was not associated with any of the histologic features. After adjusting statin therapy for symptoms, statins were associated with a decreased number of macrophages (P = .038), decreased neovascularization (P = .019), and an increased number of SMCs (P = .023). CONCLUSIONS: A number of ultrasonic texture features previously shown to be independent predictors of stroke have been found to have a strong association with established histologic features of plaque instability. This finding provides insight into the mechanism of ultrasonic texture features in stroke prediction and validates the use of ultrasound in stroke risk stratification.

Statin loading in cardiovascular surgery: never too early to treat.

PURPOSE OF REVIEW: The effects of statin loading before, during or after vascular interventions on cardiovascular and renal outcomes are discussed. Furthermore, the selection of optimal statin type and dose, according to current evidence or guidelines, is considered. The importance of treating statin intolerance and avoiding statin discontinuation is also discussed. RECENT FINDINGS: Statin loading has been shown to beneficially affect cardiovascular outcomes, total mortality and/or contrast-induced acute kidney injury, in patients undergoing vascular procedures such as percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), carotid artery stenting, endovascular aneurysm repair, open abdominal aortic aneurysms (AAA) repair and lower extremities vascular interventions. High-dose statin pretreatment is recommended for PCI and CABG according to current guidelines. Statin discontinuation should be avoided during acute cardiovascular events and vascular interventions; adequate measures should be implemented to overcome statin intolerance. SUMMARY: Statin loading is an important clinical issue in patients with cardiac and noncardiac vascular diseases, including carotid artery disease, peripheral artery disease and AAA, undergoing vascular interventions. Cardiologists and vascular surgeons should be aware of current evidence and implement guidelines in relation to statin loading, discontinuation and intolerance.

Balloon Angioplasty Versus Stenting for the Treatment of Failing Arteriovenous Grafts: A Meta-Analysis.

PURPOSE: To assess the outcomes of plain balloon angioplasty versus stenting for the treatment of failed or malfunctioning chronic haemodialysis arteriovenous grafts (AVGs). METHODS: A systematic search of the literature was undertaken using the PUBMED, EMBASE, and Cochrane databases from January 2000 to September 2016 for articles comparing balloon angioplasty versus stenting in the management of failed or malfunctioning chronic haemodialysis AVGs. Results are reported as OR and 95% CI. RESULTS: The search identified eight studies (1051 patients). Balloon angioplasty alone was used in 521 patients (49.6%) and stenting in 530 patients (50.4%). At the time of the endovascular re-intervention, the mean life of AVGs was 807.7±115.4 days for the balloon angioplasty and 714.2±96.3 days for the stenting group (p=.92). All AVGs were located in the arm. Most procedures (98.1%) were performed across the venous anastomosis, while 88% of the patients in the stenting group received a stent graft. The technical success rate was significantly higher in the stenting group (OR 0.16, 95% CI 0.08-0.31, p<.001). At 12 months, loss of primary and secondary patency was significantly higher in patients undergoing plain balloon angioplasty compared with stenting (OR 3.54, 95% CI 2.18-5.74, p<.001, and OR 1.82, 95% 1.17-2.82, p=.008, respectively). CONCLUSION: Stenting is associated with better technical success and patency rates compared with plain angioplasty in treating failed or malfunctioning chronic haemodialysis AVGs, and thus it should be considered as the first line therapeutic option.

Carotid Bifurcation Geometry as Assessed by Ultrasound is Associated with Early Carotid Atherosclerosis.

BACKGROUND: Atherosclerosis usually develops at geometrically susceptible areas, despite the impact of systemic risk factors on the entire vascular system. The aim of our study was to investigate whether carotid bifurcation geometry as assessed by ultrasound is associated with early carotid atherosclerosis, regardless of the presence of known atherosclerotic risk factors. MATERIAL AND METHODS: A nonrandomized prospective study was undertaken, including subjects of both genders, aged 50-60 years, without known cardiovascular family history, and symptoms and/or signs of cardiovascular disease. Clinical assessment and ultrasound of the carotid bifurcation evaluating geometrical characteristics, ultrasonic biopsy score (UBS), intima-media thickness (IMT), and the presence of plaque were recorded. RESULTS: Two hundred one subjects (95 men/106 women; mean age: 55 years) provided 286 carotid bifurcations associated with atherosclerotic risk factors and 114 without (one poor imaging). While UBS in the right common carotid artery (CCA) was higher in subjects with atherosclerotic risk factors but free of plaque (P = 0.035), larger diameter of the bulb (dBULB) (P < 0.001), lower ratios of internal carotid artery diameter + external carotid artery diameter/diameter of CCA ([dICA + dECA]/dCCA) (P = 0.004), and (dICA2 + dECA2)/dCCA2 (P = 0.025) were independently associated with higher CCA IMT. The presence of plaque among the total 400 carotid bifurcations was associated in the left and right CCA with lower values of bulb diameter/dCCA (dBULB/dCCA) (P = 0.014) and (dICA + dECA)/dCCA (P = 0.001), respectively. Among subjects without atherosclerotic risk factors (n = 114), the presence of plaque in the right CCA was associated with lower values of (dBULB + dECA)/dCCA (P = 0.001) and that in the left with lower values of dBULB/dCCA (P = 0.001). CONCLUSIONS: Different dimensional ratios of the carotid bifurcation assessed by ultrasound are associated with the development of early carotid atherosclerosis independently from the presence of atherosclerotic risk factors. Carotid atherosclerotic process may be side dependent.

Systematic review of laparoscopic ligation of inferior mesenteric artery for the treatment of type II endoleak after endovascular aortic aneurysm repair.

OBJECTIVE: Type II endoleak after endovascular aneurysm repair (EVAR) is frequently caused by persistent flow from the inferior mesenteric artery (IMA). The aim of this study was to assess the perioperative and midterm efficacy of laparoscopic ligation of the IMA for treatment of endoleak. METHODS: MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane databases and key references were searched with Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology for studies reporting on laparoscopic ligation of the IMA for treatment of type II endoleak after EVAR. RESULTS: Eight case studies and one study of a retrospective nature were identified. In total, 20 patients (18 men; mean age, 73.6 ± 2 years; with a mean abdominal aortic aneurysm diameter of 64.3 ± 10 mm) who underwent post-EVAR laparoscopic ligation of the IMA for type II endoleak were analyzed. The mean time from EVAR until intervention ranged from 6 to 18 months. All but one patient were asymptomatic; in 9, the aneurysm sac was enlarged, and in 11, the endoleak was considered persistent without sac enlargement. The mean procedural duration was 99 ± 24 minutes, with technical success rate of 90% (18/20); in two cases, the patients were successfully reoperated on laparoscopically in 24 hours. The mean hospitalization was 3.6 ± 1.2 days, with 0% (0/20) perioperative and 30-day mortality. No patient underwent open conversion or showed signs of intestinal ischemia. During follow-up of 32.6 ± 12 months, 13 of 20 patients had aneurysm sac regression, whereas the rest had a stable sac diameter without evidence of persistent type II endoleak. CONCLUSIONS: Laparoscopic ligation of the IMA for treatment of type II endoleak after EVAR is a feasible and safe technique in specialized centers with high technical success rate and good midterm outcomes.

Systematic Review of Off-the-Shelf or Physician-Modified Fenestrated and Branched Endografts.

PURPOSE: To determine the safety and efficacy of off-the-shelf fenestrated/branched grafts (OSFGs) and physician-modified stent-grafts (PMSGs) for the treatment of complex abdominal aortic aneurysms. METHODS: A systematic search of the MEDLINE database via PubMed from January 2001 through March 2015 retrieved 23 relevant articles evaluating the clinical outcomes following the management of patients with pararenal or thoracoabdominal aortic aneurysms. The 15 articles on PMSGs and 8 on OSFGs contained data on 308 patients (mean age 72.93±2.89 years; 213 men). The safety endpoint was major adverse events; the efficacy outcome measure was clinical treatment success (aneurysm exclusion without type I/III endoleak, permanent paralysis, long-term dialysis, or unresolved major complications). Extracted outcome data were pooled and compared between groups; data are given as the pooled proportions and 95% confidence interval (CI). Clinical data are presented as the weighted mean. RESULTS: Of the 308 patients analyzed, almost one third were operated on an emergency basis. The mean aneurysm diameters were 75.9±17.3 mm (range 56-115) for the PMSGs and 68.1±13.7 mm (range 60-100) for the OSFGs. A total of 936 renal and visceral vessels were targeted. Major adverse events (safety) occurred in 24 (12.8%) PMSG patients (95% CI 8.6% to 18.7%) and in 9 (7.4%) OSFG patients (95% CI 3.7% to 14%). Clinical treatment success (efficacy) was observed in 171/187 (91.4%) PMSG patients (95% CI 86.2% to 94.9%) and in 115/121 (95%) OSFG patients (95% CI 89.1% to 98.0%). Corresponding cumulative 30-day target vessel and branch stent perfusion rates were 97.2% (95% CI 95.1% to 98.4%) and 97.6% (95% CI 95.5% to 98.8%) for the PMSG group and 99.6% (95% CI 98.3% to 99.9%) and 98.4% (95% CI 96.5% to 99.4%) for the OSFG group. Six (3.2%) deaths occurred in the PMSG group only; 2 (1.1%) were aneurysm related. Overall branch patency was recorded in 443/458 (96.7%) and in 468/478 (97.9%) of target vessels in the PMSG and OSFG groups, respectively. CONCLUSION: Off-the-shelf and physician-modified technology seems effective and safe, in both the elective and acute settings, for the treatment of complex aortic aneurysms. Future research within a randomized trial should investigate the true limitations of these devices.

Fenestrated stent grafts for the treatment of complex aortic aneurysm disease: A mature treatment paradigm.

The introduction of fenestrated stent grafts (SGs) to treat abdominal aortic aneurysms (AAAs) with short proximal necks began in 1999. Nowadays, the whole visceral aorta can be treated totally by endovascular means. The established use of fenestrated devices to treat complex AAAs as a first-line management option has been previously reported. An up-to-date evaluation of the literature was performed including all types of publications regarding the use of fenestrated technology to repair complex AAAs. Fenestrated repair is now an established alternative to hybrid/chimney/snorkel repairs. However, specific criteria and prerequisites are required for the use and improvement of this method. Multiple device morphologies have been used incorporating the visceral arteries in various combinations. This modular strategy connects different devices (bridging covered stents and bifurcated SGs) with the aortic main body, thus excluding the aneurysm from the circulation. Precise deployment of the fenestrated SG is mandatory for successful visceral vessel revascularization. Accurate SG sizing and customization, a high level of technical skill, and facilities with modern imaging techniques including 3D road mapping and dedicated hybrid rooms are required. Most experience has been with the custom-made Zenith Cook platform, although off-the-shelf devices have been recently implanted. More complex repairs have been performed over the last few years, but device complexity has also increased. Perioperative, mid-term, and a few recently reported long-term results are encouraging. Secondary interventions remain the main problem, similar to that observed after traditional endovascular abdominal aortic aneurysm repair (EVAR).

Transition from Open Surgery to Endovascular Treatment of Abdominal Aortic Aneurysm Rupture.

BACKGROUND: To review the outcome before and after the implementation of protocol-based strategy for endovascular repair (EVAR) of abdominal aortic aneurysm rupture (rAAA). METHODS: A retrospective analysis of prospectively collected data from a tertiary center during the period 2006-2011. Demographics, comorbidities, blood examinations, perioperative patients' status, and mortality rates were recorded. Univariate and multivariate analyses were used to assess the association of the type of the procedure with various factors. RESULTS: A total of 58 (46 open surgical repair [OSR] and 12 EVAR) patients with mean age of 74 ± 17 years (91% males) were treated for rAAA. However, 39 (11 EVAR and 28 OSR) were operated with protocol-based strategy available. Total mortality rate was 52.6% (10 of 19) initially and 38.5% (15 of 39) after the implementation of a protocol-based strategy. During protocol-based treatment, the survival rate did not differ between the 2 procedures (7 of 11 EVAR and 17 of 28 OSR; P, ns). A 30-day mortality rate was associated with preoperative number of platelets (unadjusted P values, P = 0.013), age (odds ratio [OR] 0.796; 95% confidence interval [CI], 0.685-0.925; P = 0.003), and diastolic blood pressure (OR, 1.053; 95% CI, 1.016-1.093; P = 0.005). After mean follow-up of 48 ± 11 months, EVAR patients presented better outcome regarding mortality rate (36% OSR vs. 0% EVAR; P = 0.0464). CONCLUSIONS: After the adoption of an available rEVAR protocol-based strategy, EVAR and OSR were equally effective during postoperative 30 days. The role of hypotension and age is important on poor outcomes during this period. However, after midterm follow-up, EVAR demonstrates better survival rates than OSR.

One Year Outcome Using Newer Generation Endografts: A National Multicenter Study on Real Word Practice.

BACKGROUND: The aim of this study was to assess the 1 year outcomes following endovascular aortic aneurysm repair (EVAR) with the use of newer generation endografts. METHODS: Retrospective analysis was conducted of prospectively collected multicenter data from 385 EVARs. Newer endografts were defined as those introduced after 2004. Patients' demographics and comorbidities, type of operation, and abdominal aortic aneurysm (AAA) morphological characteristics were analyzed. Computer tomography was performed 1 month and 1 year post-EVAR. RESULTS: Mean age of the patients was 71.3 years; in 335 cases the intervention was elective. The mean AAA sac, neck diameter, and length were 57.15, 24.5, and 28.97 mm, respectively. Ninety-four endoleaks were recorded in 92 patients (25%), including 11 type 1a (T1aE), 3 type 1b, and 78 type 2 (T2E) endoleaks. On logistic regression analysis, neck diameter >30 mm (P = 0.032) and initial AAA sac diameter >55 mm (P = 0.031) were associated with T1aE. No association was found with T2E. Overall, 107 (27%) patients had sac expansion at 1 year associated with the presence of T2E (P = 0.019). No association was observed between T1aE or T2E and specific endograft. CONCLUSIONS: Newer generation endografts show very satisfactory performance even in difficult anatomies. T1aE was associated with initial sac and neck diameter, while AAA sac expansion was associated with the presence of T2E.