Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands.

OBJECTIVE: The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR). METHODS: This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests. RESULTS: The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively). CONCLUSION: In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Extended use of endovascular aneurysm sealing: Chimneys for juxtarenal aneurysms.

Hostile infrarenal aortic neck anatomy presents a challenge for the endovascular treatment of abdominal aortic aneurysm. Open surgical repair has been seen as the gold standard treatment for juxtarenal abdominal aortic aneurysm; however, endovascular techniques are now becoming more prevalent, particularly in patients deemed high risk for morbidity and mortality with open repair. The morphology of an aneurysm is a determinant of long-term outcomes, and short aneurysm necks are associated with poorer outcomes and a higher rate of secondary reinterventions. Parallel grafts have been used in combination with endovascular aneurysm repair to elongate the sealing zone into the paravisceral segment of the aorta. This technique is associated with a risk of proximal Type I endoleak due to "guttering." This risk may be decreased when parallel grafts are used in combination with endovascular aneurysm sealing and, as such, this technique may represent an alternative to current techniques for the treatment of juxtarenal abdominal aortic aneurysm, such as the use of conventional bifurcated grafts (with or without parallel grafts) and fenestrated endovascular stent grafts.

The Endovascular Sealing Device in Combination with Parallel Grafts for Treatment of Juxta/Suprarenal Abdominal Aortic Aneurysms: Short-term Results of a Novel Alternative.

BACKGROUND: The chimney technique using parallel grafts offers an alternative to fenestrated or branched endovascular solutions for juxtarenal and suprarenal aneurysms. Endograft deployment proximal to the renal or visceral ostia is combined with parallel stents to the aortic side branches. Application of the chimney technique using the Nellix device (Ch-EVAS) may offer some potential advantages with respect to the seal between the endograft and the parallel grafts. This study aimed to investigate the feasibility and efficacy of the Nellix endovascular aneurysm sealing (EVAS) system in conjunction with parallel grafts for the treatment of juxtarenal and suprarenal aneurysms. METHODS: A prospective evaluation of patients treated for juxtarenal and suprarenal non-ruptured aortic aneurysms using Ch-EVAS was undertaken in a single vascular unit. Patients were treated with this technique if they were unsuitable for either open repair or a custom-made complex branched/fenestrated endograft. Procedural, postoperative morbidity, and mortality data were recorded. RESULTS: Between March 2013 and April 2015, 28 patients were treated with Ch-EVAS. The median age was 75 years (range 60-87 years) and the median aneurysm diameter 66 mm (IQR 60-73 mm). Eight patients underwent suprarenal aneurysm repair including parallel grafts in the superior mesenteric artery and renal arteries. Five patients had a double chimney configuration; all the other patients were treated with a single chimney configuration. There was one 30-day or in-hospital mortality in a patient with a symptomatic aneurysm (4%) and three further deaths within 1 year of follow-up. One proximal type I endoleak and one type II endoleak occurred. Four patients underwent a reintervention. One patient experienced a transient ischemic attack and two patients suffered from a minor stroke (7%), therefore the total number of cerebrovascular complications was 11%. No patient required postoperative renal replacement therapy. CONCLUSIONS: Ch-EVAS appears to offer a feasible solution for juxtarenal and suprarenal aneurysms with adverse morphology. In this short-term follow-up endoleak rates were low and re-intervention rates were acceptable. Outcomes over extended follow-up will determine the application of this novel technique and better define which patients and aneurysm morphology can be treated effectively.

Quality of life from a randomized trial of open and endovascular repair for abdominal aortic aneurysm.

BACKGROUND: Long-term survival is similar after open or endovascular repair of abdominal aortic aneurysm. Few data exist on the effect of either procedure on long-term health-related quality of life (HRQoL) and health status. METHODS: Patients enrolled in a multicentre randomized clinical trial (DREAM trial; 2000-2003) in Europe of open repair versus endovascular repair (EVAR) of abdominal aortic aneurysm were asked to complete questionnaires on health status and HRQoL. HRQoL scores were assessed at baseline and at 13 time points thereafter, using generic tools, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36®) and EuroQol 5D (EQ-5D™). Physical (PCS) and mental component summary scores were also calculated. Follow-up was 5 years. RESULTS: Some 332 of 351 patients enrolled in the trial returned questionnaires. More than 70 per cent of questionnaires were returned at each time point. Both surgical interventions had a short-term negative effect on HRQoL and health status. This was less severe in the EVAR group than in the open repair group. In the longer term the physical domains of SF-36® favoured open repair: mean difference in PCS score between open repair and EVAR -1·98 (95 per cent c.i. -3·56 to -0·41). EQ-5D™ descriptive and EQ-5D™ visual analogue scale scores for open repair were also superior to those for EVAR after the initial 6-week interval: mean difference -0·06 (-0·10 to -0·02) and -4·09 (-6·91 to -1·27) respectively. CONCLUSION: In this study EVAR appeared to be associated with less severe disruption to HRQoL and health status in the short term. However, during longer-term follow-up to 5 years, patients receiving open repair appeared to have improved quality of life and health status.

Endovascular aneurysm sealing for infrarenal abdominal aortic aneurysms: 30-day outcomes of 105 patients in a single centre.

OBJECTIVE: Endovascular aneurysm sealing (EVAS) has been proposed as a novel alternative to endovascular aneurysm repair (EVAR) in patients with infrarenal abdominal aortic aneurysms (AAA). The early clinical experience, technical refinements, and learning curve of EVAS in the treatment of AAA at a single institution are presented. METHODS: One-hundred and five patients were treated with EVAS between March 2013 and November 2014. Prospective data were recorded on consecutive patients receiving EVAS. Data included demographics, preoperative aneurysm morphology, and 30-day outcomes, including rates of endoleak, limb occlusion, reintervention, and death. Postoperative imaging consisted of duplex ultrasound and computed tomographic angiography. RESULTS: The mean age of the cohort was 76 ± 8 years and 12% were female. Adverse neck morphology was present in 72 (69%) patients, including aneurysm neck length <10 mm (20%), neck diameter >32 mm (18%), ß-angulation >60° (21%), and conical aneurysm neck (51%). There was one death within 30 days. The incidence of Type 1 endoleak within 30 days was 4% (n = 4); all were treated successfully with transcatheter embolisation. All four proximal endoleaks were associated with technical issues that resulted in procedure refinement, and all were in patients with adverse proximal aortic necks. The persistent Type 1 endoleak rate at 30 days was 0% and there were no Type 2 or Type 3 endoleaks. Angioplasty and adjunctive stenting were performed for postoperative limb stenosis in three patients (3%). CONCLUSIONS: EVAS appears to be associated with reasonable 30-day outcomes despite the necessity of procedural evolution in the early adoption of this technique. EVAS appears to be applicable to patients with challenging aortic morphology and endoleak rates should reduce with procedural experience. The utility of EVAS will be defined by the durability of the device in long-term follow-up, although the absence of Type 2 endoleaks is encouraging.

International validation of a risk score for complications and reinterventions after endovascular aneurysm repair.

BACKGROUND: Lifelong surveillance is considered mandatory after endovascular repair (EVAR) of abdominal aortic aneurysms to detect endograft complications and prevent aneurysm rupture. Current protocols are not cost-effective or clinically effective. The international validity of the St George's Vascular Institute (SGVI) score for EVAR complications was examined. METHODS: The ENGAGE registry recruited patients undergoing EVAR at 79 centres in 30 countries. Reinterventions and endograft complications were recorded for up to 3 years after surgery. Preoperative aneurysm morphology was extracted from the registry database, and used to predict whether patients would be at low or high risk of complications after EVAR based on the SGVI score. Kaplan-Meier analysis was used to compare the incidence of endograft complications and reinterventions in patients predicted to be at low risk compared with those predicted to be at high risk. RESULTS: Some 1207 patients underwent EVAR, with follow-up of up to 3 years. The SGVI score accurately discriminated freedom from reinterventions (90·5 versus 79·3 per cent in low- versus high-risk patients; P < 0·001), freedom from endograft complications (77·9 versus 69·6 per cent in low- versus high-risk patients; P = 0·012), and freedom from a composite outcome measure of reinterventions or endograft complications (75·0 versus 66·1 per cent in low- versus high-risk patients; P = 0·006) during mid-term follow-up. CONCLUSION: This study has provided international validation of a morphological risk score that predicts mid-term reinterventions and endograft complications. The results may enable risk-stratified surveillance after EVAR.

Current endovascular management of acute type B aortic dissection - whom should we treat and when?

Aortic dissection is the most common of the acute aortic syndromes, once initiated, intimal disruption can propagate in an anterograde or retrograde fashion, and the resulting false lumen may compress the ostia of aortic branches or cause aortic expansion and eventual rupture. Acute complicated type B dissection most often requires immediate interventional treatment, whereas uncomplicated dissection has classically been managed with medical therapy alone. The first line management of complicated acute and aneurysmal chronic type B dissections has shifted toward minimally invasive endovascular treatment. To give an overview of the contemporary management of acute type B dissection, clinical manifestations, aims of management, and therapeutic options are discussed in the context deciding which patients require intervention and when.

Renal function 5 years after open and endovascular aortic aneurysm repair from a randomized trial.

BACKGROUND: Deterioration of renal function after major vascular surgery is an important complication, and may vary between patients undergoing endovascular (EVAR) or open surgical (OR) repair of an abdominal aortic aneurysm (AAA). The objective was to determine the impact of OR and EVAR on renal function after 5 years. METHODS: This was a post hoc analysis of data collected prospectively from the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial. Five years after surgery, creatinine levels were available for 189 patients (94 after OR and 95 after EVAR). The severity of renal disease was staged using the chronic kidney disease classification of the US National Kidney Foundation clinical guidelines. RESULTS: Using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, the estimated glomerular filtration rate (eGFR) for the entire group declined over time, with a mean(s.d.) preoperative value of 80·0(7·6) ml per min per 1·73 m(2) compared with 75·7(9·7) ml per min per 1·73 m(2) after 5 years (mean difference 4·2 (95 per cent confidence interval 3·2 to 5·3) ml per min per 1·73 m(2) ; P < 0·001). Five years after surgery, the mean eGFR (CKD-EPI equation) was not significantly different between the OR and EVAR groups: 76·3(9·3) versus 75·1(10·0) ml per min per 1·73 m(2) (mean difference 1·2 (-1·6 to 3·9) ml per min per 1·73 m(2) ; P = 0·410). CONCLUSION: Renal function 5 years after OR and EVAR for AAA was similar. Neither surgical procedure accelerated the loss of renal function.

Decision making in AAA repair in 2012: open or endo?

With data from four randomized trials on elective endovascular abdominal aortic aneurysm repair and many more additional post-hoc publications, the evidence can be somewhat overwhelming for the surgeon, let alone the patient. This chapter aims to present the most recent and relevant data for decision making in abdominal aortic aneurysm (AAA) repair in a comparative and concise format. After a comparison of the short- and long-term survival data of the randomized trials, the following post-hoc analyses of the four randomized trials will be presented: causes of death, reinterventions, renal function, prediction of complications, and quality of life. When both open and endovascular repair are a reasonable option for an individual patient, we need to objectively inform our patient about the available evidence from the trials. The three-fold reduction of operative mortality with endovascular repair as compared to open repair should be presented. Next, the convergence of the overall survival curves should be discussed as a key factor in the decision process. The counterintuitive observation may be considered that if endovascular repair is better for any specific subgroup it is for younger patients with low surgical risks. Finally, the patient needs to understand that the risks of reintervention and complications are higher after endovascular than after open repair and that this is even more relevant in older patients with larger aneurysms. The information that the quality of life advantage of endovascular repair is only short lived and for several domains surpassed by open repair is most likely not suitable for direct discussion with the individual patient, but it may put the procedures in the right perspective for the physician and health care managers.

Residual infrarenal aortic neck following endovascular and open aneurysm repair.

BACKGROUND: The effectiveness of open and endovascular aneurysm repair of aortic abdominal aneurysms (AAAs) can be jeopardised by deterioration of the residual infrarenal neck of the aneurysm. OBJECTIVE: The study aims to determine the length of the residual infrarenal aortic segment after endovascular and open aneurysm repair. METHODS: In a multicentre randomised controlled trial comparing open and endovascular AAA repair, 165 patients were discharged after open AAA repair (OR) and 169 after endovascular repair (EVAR). Immediately after the operation, surgeons were asked to enter in the case record form whether the level of their anastomosis after open repair was within or beyond 10 mm of the caudal renal artery. Postoperative computed tomography (CT) scans that were obtained within 6 months after surgery were used for comparative analysis. The distance between the caudal renal artery and the proximal anastomosis of the (endo-) graft was measured using axial CT slices and a standardised protocol. CT images were available and suitable for analysis in 156 (95%) of 165 OR patients and in 160 (95%) of 169 EVAR patients. Data are presented as median (range). Differences were analysed using the Mann-Whitney test. RESULTS: The distance from the caudal renal artery to the proximal anastomosis was 24 mm (16-30 mm) in the OR group versus 0 mm (0-6 mm) in the EVAR group (p < 0.0001, Mann-Whitney). In 140 of 156 (90%) patients, at least 1 cm of untreated infrarenal neck persisted after OR and in 17 of 160 (10%) after EVAR. In 84 of the 156 open repair patients (54%), the surgeon had indicated that the proximal anastomosis was within 10 mm of the caudal renal artery. Only five surgeons (6%) were accurate in this respect. CONCLUSION: After open repair, a longer segment of the infrarenal aortic neck is left untreated compared with endovascular repair and this length is underestimated by most surgeons. Long-term studies are required to determine the consequences of this difference.