The optimal operative protocol to accomplish CO2-EVAR resulting from a prospective interventional multicenter study.

OBJECTIVES: Carbon dioxide (CO2) angiography for endovascular aortic repair (CO2-EVAR) is used to treat abdominal aortic aneurysms (AAAs), especially in patients with chronic kidney disease or allergy to iodinated contrast medium (ICM). However, some technical issues regarding the visualization of the lowest renal artery (LoRA) and the best quality image through angiographies performed from pigtail or introducer sheath are still unsolved. The aim of this study was to analyze different steps of CO2-EVAR to create an operative standardized protocol. METHODS: Patients undergoing CO2-EVAR were prospectively enrolled in five European centers from 2019 to 2021. CO2-EVAR was performed using an automated injector (pressure, 600 mmHg; volume, 100 cc); a small amount of ICM was injected in case of difficulty in LoRA visualization. LoRA visualization and image quality (1 = low, 2 = sufficient, 3 = good, 4 = excellent) were analyzed at different procedure steps: preoperative CO2 angiography from pigtail and femoral introducer sheath (first step), angiographies from pigtail at 0%, 50%, and 100% of proximal main body deployment (second step), contralateral hypogastric artery (CHA) visualization with CO2 injection from femoral introducer sheath (third step), and completion angiogram from pigtail and femoral introducer sheath (fourth step). Intraoperative and postoperative CO2-related adverse events were also evaluated. χ2 and Wilcoxon tests were used for statistical analysis. RESULTS: In the considered period, 65 patients undergoing CO2-EVAR were enrolled (55/65 [84.5%] male; median age, 75 years [interquartile range (IQR), 11.5 years]). The median ICM injected was 17 cc (IQR, 51 cc); 19 (29.2%) of 65 procedures were performed with 0 cc ICM. Fifty-five (84.2%) of 65 patients underwent general anesthesia. In the first step, median image quality was significantly higher with CO2 injected from femoral introducer (pigtail, 2 [IQR, 3] vs introducer, 3 [IQR, 3]; P = .008). In the second step, LoRA was more frequently detected at 50% (93% vs 73.2%; P = .002) and 100% (94.1% vs 78.4%; P = .01) of proximal main body deployment compared with first angiography from pigtail; similarly, image quality was significantly higher at 50% (3 [IQR, 3] vs 2 [IQR, 3]; P ≤ .001) and 100% (4 [IQR, 3] vs 2 [IQR, 3]; P = .001) of proximal main body deployment. CHA was detected in 93% cases (third step). The mean image quality was significantly higher when final angiogram (fourth step) was performed from introducer (pigtail, 2.6 ± 1.1 vs introducer, 3.1 ± 0.9; P ≤ .001). The intraoperative (7.7%) and postoperative (12.5%) adverse events (pain, vomiting, diarrhea) were all transient and clinically mild. CONCLUSIONS: Preimplant CO2 angiography should be performed from femoral introducer sheath. Gas flow impediment created by proximal main body deployment can improve image quality and LoRA visualization with CO2. CHA can be satisfactorily visualized with CO2 alone. Completion CO2 angiogram should be performed from femoral introducer sheath. This operative protocol allows performance of CO2-EVAR with 0 cc or minimal ICM, with a low rate of mild temporary complications.

Endovascular aneurysm repair for symptomatic abdominal aortic aneurysms has comparable results to elective repair in the long term.

OBJECTIVE: Endovascular aneurysm repair (EVAR) has been extensively study regarding elective and ruptured abdominal aortic aneurysm (AAA) repair. However, much less is known about EVAR of symptomatic nonruptured AAA, especially concerning the long-term results. The aim of this study was to assess the outcomes of EVAR of symptomatic AAA compared with asymptomatic AAA at a tertiary center using a single graft. METHODS: All consecutive patients treated for symptomatic and asymptomatic AAAs from 1998 to 2012 at our institution, using the Cook Zenith stent graft (Cook Europe A/S, Bjaeverskov, Denmark), were included in the study. Ruptured AAAs were excluded. Patients' charts were reviewed to obtain preoperative, intraoperative, and postoperative data. All available imaging was reviewed. Life tables were constructed to assess for overall and late AAA-related survival, clinical success, and endoleak freedom. RESULTS: There were 680 patients included (137 symptomatic AAAs). No difference in technical success rate (96.1% for asymptomatic AAAs vs 94.9% for symptomatic AAAs) was present (P = .477). Thirty-day mortality was more common in symptomatic AAAs (6.6% vs 1.5% for asymptomatic AAAs; P = .002). Freedom from reinterventions was 72% ± 3% for asymptomatic AAAs vs 73% ± 5% for symptomatic AAAs (P = .785) at 10 years postoperatively. There was no difference in primary (P = .300) or secondary (P = .099) clinical success between groups, although there was higher assisted clinical success (P = .023) for asymptomatic AAAs compared with symptomatic AAAs. Persistent late clinical failure was similar in both groups (14.2% for asymptomatic AAAs vs 15.3% for symptomatic AAAs; P = .732). Freedom from late AAA-related death was higher (P = .016) for asymptomatic AAAs compared with symptomatic AAAs, but the differences disappeared when the first 30 days were disregarded. Overall survival (P = .687) was similar in both groups. An adequate aneurysm neck preoperatively conferred a better outcome in end points including overall survival. CONCLUSIONS: Symptomatic AAAs have an almost quadrupled 30-day mortality compared with asymptomatic AAAs, but the outcome differences fade in the long term. An adequate aneurysm neck was associated with better outcomes including overall survival independent of the initial presentation of the AAA. These results suggest the need of improving the identification of symptomatic patients requiring preoperative medical optimization. However, this is often limited by the acute need of the procedure, and more intensive postoperative monitoring may have greater potential. Independently, a strict anatomic selection for infrarenal EVAR is of paramount importance for the long-term outcome.

Low Iliofemoral Calcium Score May Predict Higher Survival after EVAR and FEVAR.

BACKGROUND: Abdominal aortic aneurysm is associated with an increased mortality, mostly cardiovascular events. Moreover, aortoiliac calcification is associated with increased mortality in patients with peripheral occlusive disease. The aim of this study is to assess the potential association between iliofemoral calcification, assessed by calcium score, in patients undergoing infrarenal (endovascular aneurysm repair [EVAR]) or fenestrated endovascular aortic repair (FEVAR) and long-term mortality, particularly caused by cardiac events. METHODS: All patients with preoperative noncontrast-enhanced computed tomographic scans who underwent infrarenal EVAR and FEVAR of nonruptured abdominal aortic aneurysm between 2004 and 2012 at a single tertiary center were screened for inclusion. Agatston calcium score was measured from the aortic bifurcation to common femoral arteries using a dedicated postprocessing software. The values are presented as median and interquartile range. RESULTS: About 404 (62.05%) of 651 patients who underwent EVAR and FEVAR had sufficient imaging quality to be included. There was no difference in survival between included and excluded patients (P = 0.33). Nine patients (2.2%) died within 30 days of the operation, whereas the remaining were followed up for 6.3 (4.7-8.4) years. The iliofemoral calcium score was 8348 (3830-14,179). Estimated overall survival at 5 years was 73 ± 2%. Patients within the lowest quartile of iliofemoral calcium score had significantly higher overall survival (5 years: 79 ± 4% vs. 71 ± 3%; P = 0.01) and cardiac event-free survival (5 years: 95 ± 2% vs. 91 ± 2%; P = 0.033) when compared with the remaining ones. Calcium score was associated with neither univariate regression analysis with survival (odds ratio, 1.016 [0.988-1.045]; P = 0.268) nor cardiac event-free survival (odds ratio, 1.024 [0.986-1.063]; P = 0.222). CONCLUSIONS: Low iliofemoral calcium score may be associated with lower incidence of fatal cardiac events and all-cause long-term mortality after EVAR and FEVAR. This may be partially a reflection of aging and cardiovascular comorbidity but needs to be studied further.

The Use of Iliac Branched Devices in the Acute Endovascular Repair of Ruptured Aortoiliac Aneurysms.

BACKGROUND: The objective of this study was to evaluate the feasibility and midterm outcomes of iliac branch devices (IBDs) to preserve the internal iliac artery perfusion in emergent endovascular repair of ruptured aorto-iliac aneurysms. METHODS: Between December 2012 and July 2017, a total of 8 IBDs were implanted in 6 patients (the median age 65 years; all men) in a single tertiary referral center. The indication for IBD implantation was a ruptured abdominal aortic aneurysm with a concomitant common iliac artery aneurysm (n = 4) or isolated CIA aneurysms (n = 2). The main outcome measures were technical and clinical success. The secondary outcomes were primary and primary assisted patency, the occurrence of type I/III endoleaks, and reinterventions. RESULTS: All patients were hemodynamically stable during the procedures, which were performed under local anesthesia. Technical success was achieved in all cases (the median total procedure time of 188 min and the median IBD procedure time of 28 min). The median follow-up was 34 months (interquartile range 19-78). There were no deaths during the follow-up and no major complications unrelated to the IBD. Two (25%) secondary interventions were performed for IBD occlusion in patients with bilateral IBDs. The other reintervention was a type II endoleak embolization in 1 of these 2 patients. The freedom from reintervention estimate was 75% through 2 years. The overall primary assisted patency was 100% through 3 years. CONCLUSIONS: The use of IBDs in the acute setting is feasible to exclude ruptured aortoiliac aneurysms while maintaining pelvic circulation. The secondary intervention rate is considerable; however, the midterm assisted primary patency rates are promising. Further studies are needed to guide patient selection and to evaluate longer term outcomes.

Nationwide Study on Treatment of Mycotic Thoracic Aortic Aneurysms.

OBJECTIVE: Mycotic aortic aneurysms are rare, life threatening, and complex. This nationwide study aimed to assess outcome after repair of mycotic thoracic aortic aneurysms (MTAAs). METHODS: Patients treated in Sweden for MTAAs between 2000 and 2016 were identified in the Swedish vascular registry (2010-16) and local patient registries (2000-09). Primary outcome was survival, and secondary outcomes included surgical strategy, rate of infection related complications (IRC), and re-operations. RESULTS: Fifty-two patients (median age 71 ± 8.1 years; 28 [54%] men, 13 [25%] ruptured) were identified (3.6% of all thoracic aortic aneurysm repairs in Sweden). Aneurysm location was aortic arch (n = 6; 11%), descending aorta (n = 42; 81%), and multiple locations (n = 4; 8%). Twenty-nine (56%) patients had positive cultures; the most prevalent agent was Staphylococcus aureus (n = 16; 31%). Operative techniques included thoracic endovascular aortic repair (TEVAR; n = 35 [67%]), fenestrated/branched TEVAR (n = 8; 15%), hybrid repair (n = 7; 14%), and open patch repair (n = 2; 4%). Survival was 92% (95% confidence interval [CI] 88-96) at 30 days, 88% (95% CI 84-93) at three months, 78% (73-84) at one year, and 71% (64-77) at five years. The mean follow up among survivors (> 90 days) was 45 months (range 4-216 months). Antibiotics were administered for a median of 15 weeks (range 0-220 weeks). IRCs occurred in nine patients (17%): sepsis (n = 3), graft infection (n = 3), recurrent mycotic aneurysm (n = 1), aorto-oesophageal/bronchial fistula (n = 2). Six (67%) IRCs were fatal; 80% occurred within the first year. Re-operations were performed in nine patients (17%). CONCLUSIONS: TEVAR was often used as treatment for MTAAs, with acceptable short- and long-term survival when compared with open cohorts in the literature. IRCs are of concern and warrant follow up and long-term antibiotic treatment.

The role of CT-assessed sarcopenia and visceral adipose tissue in predicting long-term survival in patients undergoing elective endovascular infrarenal aortic repair.

OBJECTIVES: To evaluate if ileo-psoas muscle size and visceral adipose tissue can predict long-term survival after EVAR. METHODS: Patients who underwent EVAR between 2004 and 2012 in a single center were included. Total psoas muscle area (TPA), abdominal visceral adipose tissue (VAT) area, subcutaneous adipose tissue (SAT) and total adipose tissue (TAT) were measured on the pre-operative CT. Primary endpoint was all-cause mortality. Values are presented as median and interquartile range or absolute number and percentage. Cox regression analyses were performed to assess the associations with mortality. RESULTS: Two hundred eighty-four patients could be included in the study. During a median follow-up of 8 (4-11) years, 223 (79.9%) patients died. Age (P = < .001), cardiovascular (P = .041), cerebrovascular (P = .009), renal diseases (P = .002) and COPD (P = < .001) were independently associated with mortality. TPA was associated with mortality in a univariate (P = .040), but not in a multivariate regression model (P = .764). No significant association was found between mortality and TPA index (P = .103) or any of the adiposity measurements with the exception of SAT (P = .040). However, SAT area loss in a multivariate analysis (P = .875). CONCLUSIONS: assessment of core muscle size and visceral adipose tissue did not contribute to improving the prediction of long-term survival after EVAR. ADVANCES IN KNOWLEDGE: The finding of this study contradicts the previously claimed utility of core muscle size and visceral adipose tissue in predicting long-term survival after EVAR.

Ilio-femoral calcium score may assist Glasgow Aneurysm Score prediction of long-term survival of low-risk patients after infrarenal EVAR.

BACKGROUND: The aim of this study is to evaluate if ilio-femoral calcium score (CS) combined with Glasgow Aneurysm Score (GAS) can improve the prediction of long-term survival after EVAR. METHODS: All the patients who underwent infrarenal endovascular aortic repair (EVAR) for non-ruptured AAA between January 2004 and December 2012 at a tertiary referral center were retrospectively included if the preoperative imaging was of sufficient quality and they had survived for more than 30 days. Preoperative non-contrast enhanced CT were used to measure ilio-femoral calcium score using dedicated postprocessing software. GAS was calculated and patients were divided into low or high GAS by a cutoff of 80. RESULTS: Two hundred and eighty-eight out of 500 patients were included in the study with no difference in survival compared to excluded patients (P=0.529). Patients were followed-up for a median of 7 (range 4-9) years. GAS correlated positively with ilio-femoral calcium score (r=0.123; P=0.037). One hundred and thirty-five patients (46.9%) had low GAS, and 153 (53.1%) had high GAS. Patients with high GAS had lower survival compared to the ones with low GAS (P≤0.0001). GAS was associated with long-term mortality in a uni- and multivariate regression (P≤0.0001 and P≤0.0001). Ilio-femoral calcium score was significantly associated with mortality in the group with low GAS (P=0.028), but not in the group with high GAS (P=0.297). Significance retained in multivariate regression analysis (P=0.029). Moreover, in the low GAS group, ilio-femoral calcium score was further divided in high and low according to the median. Patients with high calcium score had lower survival compared to the ones with low calcium score (P=0.047). CONCLUSIONS: Long-term survival in patients who have had infrarenal EVAR can be predicted by the clinically based Glasgow Aneurysm Score. Measuring the ilio-femoral calcium score preoperatively may refine GAS assessment in low-risk patients.

The use of a novel short dilator tip on the distal bifurcated component during fenestrated aortic repair to avoid reno-visceral bridging stents.

BACKGROUND: The aim of this study was to evaluate the feasibility and efficacy of a modified delivery system of the distal bifurcated FEVAR component where the dilator tip was shortened to prevent damage to the renovisceral bridging stents. METHODS: All consecutive patients from a tertiary referral center that underwent a FEVAR with a custom delivery system of the distal bifurcated endograft with a short tip between November 2017 and July 2019 were retrospectively analyzed. Only patients with complete fluoroscopic loops of the insertion and deployment of the distal endograft were included. The primary study endpoint was the degree of crossing of the fenestration bridging stent-grafts, that was graded as 'not crossing', 'partial crossing' and 'complete crossing' relative to the lowermost placed fenestration. Secondary endpoints included fenestration related adverse events, secondary interventions, changes in renal function, aneurysm related mortality and overall mortality. RESULTS: 23 patients were included (21 (91%) juxta-renal aneurysms, 2 TAAA type IV (9%). The lowermost fenestration was crossed in 4 (17.3%), partially crossed in 9 (39.1%) and not crossed in 10 (43.4%) cases. Partial compression or inadequate flaring of a fenestration stent-graft was identified in the intraoperative cone beam CT in 6 (26.0%) patients and corrected peri-operatively. Technical success was 100%. Median follow-up was 34 (27-38) months with two non-aneurysm related deaths during this period. Four patients (17.3%) underwent a secondary intervention related to a fenestration bridging stent-graft. CONCLUSIONS: The use of a custom short dilator introducer tip on the bifurcated device during FEVAR reduces the need to cross the fenestration bridging stent-grafts and may result in less fenestration related adverse events. However, the reno-visceral segment is still frequently crossed by the iliac extension which may lead to adverse events. This could likely be avoided by a similar adaptation on the iliac extension delivery system.

Crushing of a bridging stent during follow-up of endovascular branched aortic arch repair: A novel mode of failure.

A 68-year-old man developed aneurysmal degeneration of the aortic arch and proximal descending aorta after an open ascending graft for a type A aortic dissection. A three-branched endovascular aortic arch repair was performed with patency of all branches despite some degree of initial misalignment of the branches in relation to the target vessels. At 6 months postoperatively, an asymptomatic partial crushing of the left common carotid bridging grafts was observed on computed tomography angiography. This was treated by reinforcing the branch with a balloon-expandable endograft. The postoperative course was uneventful but a computed tomography angiography after 1 month showed recurrent asymptomatic compression. A left carotid-subclavian bypass was eventually performed. We have reported a new failure mode of an inner branch arch repair of residual type A chronic dissection.

Steerable sheath for exclusively femoral bilateral extension of previous fenestrated endovascular aneurysm repair with iliac branch devices.

We report the treatment of type Ib endoleak after fenestrated endovascular aneurysm repair (FEVAR) with iliac branch device (IBD) to allow exclusive transfemoral access without a femoral-to-femoral through-and-through wire. The patient was treated with fenestrated endovascular aneurysm repair and showed expansion of the aneurysm owing to a type Ib endoleak. An IBD was implanted by the use of a contralateral steerable sheath for internal iliac artery catheterizing. A computed tomography scan showed the patency of the target vessels and resolution of the endoleak. The use of a steerable sheath without femoral-to-femoral through-and-through wire to bridge the internal iliac artery in patients receiving an IBD after prior EVAR is feasible and avoids the risks associated with upper extremity access.