Stent graft surface movement after infrarenal abdominal aortic aneurysm repair: comparison of patients with and without a type 2 endoleak.

OBJECTIVES: The aim was to compare multidirectional stent graft movement in patients with and without a type 2 endoleak. METHODS: This was a retrospective case control study of patients being followed up after elective endovascular aneurysm repair of abdominal aortic aneurysms. The post-procedural and final follow up multislice computed tomography (MSCT) of 69 patients with and 74 without a type 2 endoleak were analyzed. Three dimensional (3D) surface models of the stent graft, delimited by landmarks using custom built software, were derived from these MSCT data. The stent graft was segmented in different zones, and the proportion of the total stent graft surface moving >9 mm between the post-procedural and the final follow up MSCT was calculated, given in percentages, and compared between groups. Changes of infrarenal neck, renal artery to stent graft distance, and freedom from stent graft related endoleaks were evaluated. RESULTS: Overall surface movement was higher in the no endoleak (18.8%, IQR 0.1-45.1%) than in the type 2 endoleak group (5.3%, IQR 0-29.7%; p = .06). Furthermore, significantly higher surface movement in the no endoleak group was found in the proximal anchoring zone (p = .04) and the distal left limb (p = .01), which was the modular limb in 81.1% (p < .01). Neck diameter increase (1.0 mm, IQR 0-3.0 mm; p < .01) and renal artery to stent graft distance difference (0 mm, IQR 0-3.3 mm; p < .01) were significantly higher in the no endoleak group. Five patients in the no endoleak and one patient in the type 2 endoleak group suffered from a stent graft related endoleak (p = .27). CONCLUSIONS: The presence of a type 2 endoleak is associated with decreased surface movement of the proximal anchoring zone and the distal modular limb of bifurcated stent grafts.

Diagnostic workup of primary sclerosing cholangitis: the benefit of adding gadoxetic acid-enhanced T1-weighted magnetic resonance cholangiography to conventional T2-weighted magnetic resonance cholangiography.

AIM: To evaluate the value of gadoxetic acid-enhanced T1-weighted (T1W) magnetic resonance cholangiography (MRC) versus conventional T2-weighted (T2W) MRC compared to endoscopic retrograde cholangiopancreatography (ERCP) in patients with primary sclerosing cholangitis (PSC). MATERIALS AND METHODS: Based on T1W MRC, PSC patients were classified into a regular (RG) and a delayed (DG) excreting group, with an absence of gadoxetic acid in the common bile duct at 20 min. Beading, pruning, and gradation of central bile duct stenosis, evaluated by T1W and T2W MRC, were compared to ERCP. Liver parenchymal enhancement was measured in both study groups and compared to a reference group (n = 20) without a history of liver disease. Two readers performed all measurements. RESULTS: Based on beading and pruning of the peripheral bile ducts, sensitivities, specificities, and accuracies for reader 1 were 0.17/0.43, 0/0.17, and 0.15/0.31 for T1W MRC, and 0.83/0.86, 1/0.83, and 0.85/0.85 for T2W MRC (p = 0.004). For reader 2 sensitivities, specificities, and accuracies were 0.25/0.57, 0/0.33, and 0.23/0.46 for T1W MRC, and 0.92/1, 1/0.83, and 0.92/0.92 for T2W MRC (p = 0.012). Compared to ERCP, central bile duct stenoses were significantly overestimated (p < 0.001) by T2W MRC. A significantly lower parenchymal enhancement was found in the DG (n = 7) compared to the RG (n = 13), and compared to the reference group (p < 0.001). CONCLUSION: The combined performance of T2W and T1W MRC may provide a comprehensive imaging workup of PSC, including morphological and functional information resulting in optimal management.

Aortomonoiliac endografting after failed endovascular aneurysm repair: indications and long-term results.

OBJECTIVES: To present long-term results of endoleak/endograft migration treatment by aortomonoiliac (AMI) endografting after failed endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms. DESIGN: Post hoc analysis of a prospectively gathered database at a tertiary care university hospital. MATERIALS AND METHODS: From March 1995 to November 2010, 23 patients were identified who underwent modification into AMI configuration after failed elective EVAR. Major causes for modification were type I (with/without endograft migration) or type III endoleaks with aneurysm expansion. An average increase in aneurysm size of 1.6 cm (range: -1.5 to 10.5 cm) since initial aneurysm treatment was observed. Interventional outcomes and long-term results were recorded for analysis. RESULTS: Technical success rate of AMI endografting was 95.65% (n = 22). All except two endoleaks could be successfully sealed with this manoeuvre (94.44%). Median time to modification was 5.3 years (interquartile range Q1-Q3: 1.3-9.3 years). No intra-operative conversion to open surgery was necessary and mortality was 0%. Median follow-up was 44 months (interquartile range Q1-Q3: 17-69 months). CONCLUSIONS: Treatment of graft-related endoleaks/endograft migration by AMI endografting after failed EVAR represents a safe and feasible procedure. This approach broadens the minimal invasive opportunities of aneurysm treatment, and open surgical conversion may be avoided except in selected patients.

Elective abdominal aortic aneurysm repair: does the aneurysm diameter influence long-term survival?

OBJECTIVES: The aim of this study was to investigate whether initial abdominal aortic aneurysm (AAA) diameter influences long-term survival after elective repair. DESIGN: Retrospective analysis of database. MATERIAL AND METHODS: Between March 1995 and December 2006, a consecutive series of 895 patients underwent elective treatment of an AAA either by open surgical or endovascular repair. An AAA diameter of 5.5cm was chosen as threshold to distinguish between small and large aneurysms, according to the definition given by the UK small aneurysm trial. Patient characteristics and distribution of basic risk factors were assessed. Survival estimates (Kaplan-Meier) and Cox proportional hazards regression results are reported. RESULTS: Patients with small aneurysms were more likely to survive the first 6 years after AAA repair, even after adjustment for treatment modality and baseline risk factors. After adjustment for age and sex aneurysms with smaller diameter were related to a lower risk of death (p<0.0016). CONCLUSIONS: Patients with small aneurysms (< or =5.5cm) have an improved long-term survival than patients with larger aneurysms.

The impact of endovascular stent grafting on reducing mortality rates after surgical treatment of abdominal aortic aneurysms.

OBJECTIVES: to investigate whether appropriate selection in patients with infrarenal abdominal aortic aneurysms (AAA) for transfemoral endovascular aneurysm management (TEAM) or open graft replacement (OGR) may decrease in-hospital mortality rates (MR). DESIGN: analysis of a clinical series over three periods in an university vascular center. Conclusions of the second period were drawn and prospectively applied in a third period and compared. METHODS: during the period 1989-1994 only OGR was available (n=170). In the interval 1995-2000 either OGR or TEAM were carried out (n=454). During the period 01/2001-07/2002 the conclusions concerning selection of treatment modality were drawn and prospectively applied in 132 consecutive patients. MR were recorded and possible significant differences were checked. RESULTS: during the first period MR was 6.5%. Overall MR decreased to 3.7% in the second interval. Overall MR of the last period was improved to 1.5% (p<0.05). No patient died after OGR (0% vs 6.5%, p<0.04). As all patients with significant individual risk profiles were treated by TEAM, MR slightly increased (2.9%), but the difference remained insignificant (2.4% in period 2). CONCLUSIONS: risk adjusted selection of treatment modality influences the results after OGR significantly, thereby reducing overall MR of elective AAA treatment.