Midterm results of endovascular versus open surgical repair for infrarenal abdominal aortic aneurysms in low surgical risk patients.

OBJECTIVE: The objective of this study was to analyze midterm outcomes of endovascular repair (EVAR) versus open repair (OR) for treatment of infrarenal abdominal aortic aneurysms (AAAs) in low surgical risk patients. METHODS: Elective patients with AAAs undergoing treatment from 2003 to 2017 in a single, tertiary-care institution were evaluated. All patients with a low preoperative risk of complications and perioperative mortality (Medicare Aneurysm Scoring System <3) were included, and rates of perioperative and long-term mortality, adverse events, and reintervention were evaluated for EVAR and OR. A propensity score-matched cohort, leveling age, risk factors, and comorbidities was additionally performed. RESULTS: A total of 227 patients were included (EVAR 59.9% and OR 40.1%) and followed for a mean of 80 ± 48 months. Patients undergoing EVAR were older (66.6 ± 5 vs. 64.1 ± 6 years; P <.001), had a higher body mass index (29.6 ± 4 vs 28.1 ± 3 kg/m2; P = .005), a higher prevalence of chronic obstructive pulmonary disease (27.3% vs 9.9%; P = .001), and lower prevalence of dyslipidaemia (46.3% vs 65.9%; P = .004). Patients undergoing OR had a higher rate of major adverse events (19.7% vs 2.6%; P = .001) and 30-day reinterventions (8.8% vs. 1.5%; P = .016), with 30-day mortality being 0% in both groups. The propensity-score matched cohort included 76 matched pairs (1:1), with differences in hospital stay and major complications remaining significant, without affecting mortality. At 5-year follow-up, there were no significant differences in the reintervention rate (EVAR 18.5% vs OR 17.6%; P = .67) or survival (EVAR 85% vs OR 91%; P = .195). CONCLUSIONS: In low surgical risk patients with AAAs, EVAR may offer comparable midterm results to OR, with a lower rate of major adverse events and a shorter in-hospital stay. With the current OR-first paradigm in low-risk patients, several factors should be taken into account for decision-making (anatomic suitability, risk of sexual dysfunction, risk of type 2 endoleaks, and need for follow-up).

Results of Transarterial Embolization for Treating Type 2 Endoleaks: A Single-Center Experience.

BACKGROUND: Type 2 endoleaks (T2Es) are the main cause of reintervention after endovascular repair of abdominal aortic aneurysms (EVAR). The objective of this study is to quantify success rates of T2E treatment. METHODS: This study involves a retrospective analysis of a prospectively maintained database containing data on all consecutive patients treated for a T2E between 2003 and 2017 in a single center. Technical success was defined as absence of endoleak in the final angiographic control after treatment. Clinical success was defined as absence of sac growth over 5 mm in the contrast-enhanced computed tomography performed a year thereafter. Statistics included Kaplan-Meier survival estimates. RESULTS: A total of 528 elective EVARs were performed in the period. Thirty-six of these (6.8%) developed a T2E requiring reintervention, a median of 37.9 months after EVAR. Twenty-five percent of the treatments were performed more than 5 years after intervention. Twenty-eight of the 36 treatments were performed via transarterial embolization. For this technique, technical success was 71.4% and clinical success was 62.5%. A subsequent reintervention was required in 35.7% of patients. In this cohort, the rate of aneurysm rupture was 10.7% (n = 3/28), open surgical conversion was needed in 2 of 28 cases (7.1%), and rate of aneurysm-related death was 14.3% (n = 4/28) over follow-up. CONCLUSIONS: A high percentage of patients are at risk of adverse outcomes after T2E treatment. Strict imaging follow-up is still needed in this population.

Predictive Factors of Aneurysm Sac Growth in Patients with a Type II Endoleak in the First Post-EVAR Control.

BACKGROUND: The objective of this study was to identify predictive factors associated with aneurysm sac growth over time in patients diagnosed with a type II endoleak (TII-EL) in the first postoperative control after endovascular aneurysm repair (EVAR). METHODS: A retrospective analysis of all patients undergoing an elective EVAR procedure from January 2003 to December 2011 (9 years) in a single center was performed. Patients with a TII-EL detected in the first post-EVAR imaging control and with over twelve months of follow-up were included. The primary end point was aneurysm sac growth > 5 mm from the first month computed tomography angiography (CTA) to the last available CTA. Demographic variables, cardiovascular risk factors, comorbidities, aneurysm-related data, and procedural information were collected. Three-dimensional volume rendering with the Mimics ® software (Materialise NV, Leuven, Belgium) was used to measure the endoleak nidus. Descriptive, univariate, and multivariate analyses (Cox proportional hazards model) were performed. RESULTS: In this period, 220 EVAR procedures were performed. 63 TII-ELs (28.7%) were detected in the first CTA control (90.5% male, mean age: 75.7 ± 8 years). After a median follow-up of 54 months (interquartile range [IQR], 56.5), aneurysm sac growth > 5 mm was detected in 19 patients (30.1%). Age (P = 0.02) and dyslipidemia (P = 0.03) were associated with sac growth > 5 mm, whereas the presence of chronic obstructive pulmonary disease (COPD) behaved as a protective factor (P = 0.02). The craniocaudal length of the endoleak nidus (P < 0.01) and the nidus volume (P < 0.001) were the only aneurysm-related variables associated with sac growth. Age (HR: 14.1, 95% CI: 2.1-92.3, P = 0.006) and the presence of COPD (HR: 9.6, 95% CI: 1.4-63.7, P = 0.019) were the only independent predictors in the multivariate analysis. CONCLUSIONS: Reliable predictors of long-term aneurysmal sac growth are lacking, although some variables such as age or nidus volume appear to be associated. Strict surveillance remains mandatory.