Long-term outcomes of the Endurant endograft in patients undergoing endovascular abdominal aortic aneurysm repair.

OBJECTIVE/BACKGROUND: To investigate the long-term outcomes after endovascular aneurysm repair (EVAR) in a real-world setting using the Endurant endograft (EG). METHODS: 184 EVAR candidates treated with the Endurant family EGs in a single vascular center were prospectively enrolled from January 2009 to December 2016. Kaplan-Meir estimates of long-term standardized primary and secondary outcome measures were performed. Per protocol, subgroup comparison analysis was performed in three groups: patients treated within instructions for use (in-IFU) vs patients treated outside IFU (outside-IFU), EVAR in patients receiving the Endurant proximal diameter 32 or 36 mm EG vs those receiving the <32 mm diameter EG and EVAR with various Endurant EG versions. RESULTS: The mean follow-up was 75.09 ± 37.9 months (range: 4.1-172 months). The median age of the patients was 72.96 ± 7.03 years (range: 55-88 years). A total of 177 patients were male (96.2%). Compliance with IFU was followed in 107 patients (58.2%). Overall survival was 69.5% and 48% at 5 and 8 years, respectively. Of the 102 all-cause deaths, 7 (6.9%) were aneurysm related. Six of these postimplant deaths occurred in patients presented with aneurysm rupture from type Ia or/and type Ib endoleak. At 5, 8, and 10 years of observation, freedom from aneurysm rupture, open surgical conversion, type I/III endoleak, any type of endoleak, aneurysm-related secondary intervention probabilities, and neck-related events were as follows: 98.1%, 95%, and 89.4%; 95.1%, 91.2%, and 85.7%; 93.6%, 87.3%, and 83.9%; 83.4%, 74%, and 70.9%; 89.8%, 76.7%, and 72%; and 96.3%, 90%, and 87.6%, respectively. Corresponding clinical success was 90%, 77.4%, and 68.4%, respectively. Patients treated outside-IFU had significantly higher risk of aneurysm rupture, open surgical conversion probability, occurrence of type I/III endoleak, and chance of reinterventions and lower clinical success probabilities compared with the in-IFU counterparts at 5 and 8 years. This statistical difference remained when type Ia endoleak or endoleak of any type was considered independently. In addition, it was stronger in patients having extreme anatomic boundaries (>1 hostile anatomic condition), when aneurysm-related death, aneurysm rupture, and clinical success at 5 years were considered. Overall proximal migration and limb occlusion were recorded in 1.1% and 4.9% of the patients, respectively. Overall reintervention rate was 17.4%. An increase in aneurysm sac diameter was observed in 12.5% of patients and was not related to IFU status. The Endurant version or the proximal EG diameter had no significant association with the chance of any complication or adverse event. CONCLUSIONS: The data confirmed the durability of the Endurant EG, achieving promising long-term outcomes in a real-world setting. However, its positive performance must be interpreted with caution in patients treated off-label especially those with extreme anatomic boundaries. In this cohort, some of EVAR advantages might be lost in the late future. Further similar studies are warranted.

Lessons Learned from Open Surgical Conversion after Failed Previous EVAR.

BACKGROUND: Delayed open conversion (OpC) after endovascular aortic aneurysm repair (EVAR) is becoming increasingly common worldwide. We reviewed our experience to characterize the perioperative spectrum of OpC repairs. MATERIALS AND METHODS: A retrospective analysis of a prospectively maintained institutional database to identify patients who underwent late OpC after failed EVAR was performed. Patient and aneurysm baseline characteristics, mechanism of failure, perioperative details, including type of repair/complications/survival, and late outcomes were examined. RESULTS: From January 2003 to January 2020, 38 male patients (mean age, 75 ± 7 years; range, 60-90) required late OpC. Interval time from initial EVAR to OpC was 63.6 ± 33.8 months (range, 17-120). Mean diameter of the aneurysms was 82.2 ± 22.1 mm before OpC compared with 62.9 ± 13 mm before endograft implantation. Mechanisms of failure were type Ia, Ib, II, and III endoleaks in 14 (36.8%), 9 (23.7%), 4 (10.5%), and 1 (2.6%) patient(s), respectively; infection in 3 (7.9%), leg ischemia in 2 (5.3%), and multiple causes in 5 (13.2%) patients. We observed 4 (10.5%) asymptomatic, 16 (42.1%) symptomatic, and 18 (47.3%) ruptured aneurysms. Four patients (10.5%) had stable contained ruptures, whereas the remaining 13 (34.2%) and 1 additional patient (2.6%) with aortoenteric fistula presented with hemorrhagic shock (class ≥II). Total endograft explantation, endograft preservation, or proximal/distal partial graft removal was performed in 16 (42.1%), 10 (26.3%), and 2 (5.2%)/9 (23.7%) of patients, respectively. Technical success was 100%, excluding an early postaortic clamping death. Overall, 30-day mortality was 21.1% (8 of 38) and significantly higher in patients with hemorrhagic shock or hemodynamic instability at presentation (P = 0.04 and P = 0.009, respectively) and in patients who had endografts with hooks/barbs or experiencing higher postoperative complication rate (P = 0.02 and P = 0.006, respectively). By definition, procedure success was 81.1%. Mean follow-up was 37.6 ± 39.8 months. By the end of the study, we recorded 11 deaths (2 were aneurysm related). CONCLUSIONS: Despite high technical success, OpC has a significant mortality in patients presenting with hemorrhagic shock and had active fixation endografts or experiencing high complication rate. Many other confounding factors may play a role.

Correlation of Baseline Plasma and Inguinal Connective Tissue Metalloproteinases and Their Inhibitors With Late High-Pressure Endoleak After Endovascular Aneurysm Repair: Long-term Results.

Purpose: To investigate whether plasma and connective tissue matrix metalloproteinases (MMP) and their inhibitors (TIMP) may predict late high-pressure endoleak after endovascular aneurysm repair (EVAR). Materials and Methods: Samples of inguinal fascia and blood were collected in 72 consecutive patients (mean age 73.1 years; 68 men) undergoing primary EVAR with the Endurant stent-graft. Baseline plasma levels of MMP-2, MMP-9, TIMP-1, and TIMP-2 and baseline MMP-2 and MMP-9 activity estimated using gelatin zymography (GZ) were compared between patients who developed late endoleak in follow-up and those who did not. Subgroup analyses were performed between patients with (n=18) and without inguinal hernias and between patients with moderate-diameter (50-59 mm; n=45) or large-diameter (≥60 mm; n=27) abdominal aortic aneurysms (AAA) at primary EVAR. Results: The mean follow-up period was 63.1 months (range 7.5-91.5), during which time 13 (18.1%) patients developed type I (6 Ia and 5 Ib) or 2 type III endoleaks. Only GZ-analyzed proMMP-9 concentrations were higher in the endoleak group than in patients without endoleak (mean difference 8.44, 95% CI -19.653 to -1.087, p=0.03). The patients with primary inguinal hernia at presentation had significantly higher tissue TIMP-2 values (0.8±0.7 vs 0.5±0.4, p=0.018) but lower plasma total (pro- + active) MMP-9 values (11.9±7.8 vs 16.2±7.4, p=0.042) than patients without hernias at the time of EVAR. Patients with AAAs ≥60 mm had significantly higher mean tissue homogenate levels of total (pro- + active) MMP-9 (p=0.025) and total (pro- + active) MMP-2 (p=0.049) as well as higher proMMP-9 (p=0.018) and total (pro- + active) MMP-9 (p=0.021) levels based on GZ compared to patients with moderate-diameter AAAs. Regression analysis revealed a significant association between total (pro- + active) MMP-9 plasma samples and the presence of hernia (OR 0.899, 95% CI 0.817 to 0.989, p=0.029) and between GZ-analyzed proMMP-9 and late endoleak (OR 1.055, 95% CI 1.007 to 1.106, p=0.025). GZ-analyzed proMMP-9 and active MMP-9 were strong predictors of late endoleak in patients with hernia (p=0.012 and p=0.044, respectively) and in patients with AAAs ≥60 mm (p=0.018 and p=0.041 respectively). Conclusion: Inguinal fascial tissue proMMP-9 significantly predicted late endoleak. ProMMP-9 and active MMP-9 biomarkers are significantly associated with late endoleak in hernia patients and in patients with AAAs ≥60 mm. Considering the clinical association between hernia and AAA and the fact that the AAA wall connective tissue environment remains exposed to systemic circulation after EVAR, inguinal fascia extracellular matrix dysregulation and altered MMP activity may reflect similar changes in AAA biology, leading to complications such as endoleak.

A Rare and Dangerous Combination of COVID-19, Lemierre Syndrome, and Carotid Pseudoaneurysm: A Case Report.

Lemierre syndrome is a rare complication of oropharyngeal infection that causes septic thrombophlebitis in the internal jugular vein. Since the onset of the COVID-19 pandemic, this condition has been dangerously overlooked and poses an even greater threat when complicated by vascular pathologies. A case is presented where the patient required emergency endovascular exclusion of a right internal carotid artery pseudoaneurysm due to Lemierre syndrome. The treatment included stent graft placement and drainage of a neck abscess, along with appropriate antibiotic treatment during hospitalization. Recognizing this diagnosis requires a high index of suspicion, particularly during the COVID-19 pandemic. The complexity of the disease necessitates extensive multidisciplinary collaboration for effective treatment.

Challenging Endovascular Treatment of Coral Reef Aorta and a Literature Review.

Coral reef aorta is a rare type of atherosclerotic disease that causes severe calcification in the abdominal aorta. We present a case of coral reef aorta with hemodynamically significant symptomatic aortic stenosis causing intermittent claudication and bilateral cyanosis of the toes. Despite the challenging anatomy for endovascular treatment, the patient underwent successful transfemoral endovascular stent-graft placement. The endovascular intervention with stents is a viable alternative method and, in many cases, constitutes the first choice for the treatment of coral reef aorta.

Combined AFX2 with thoracic stent graft: A different endovascular approach of an abdominal aorta aneurysm.

The AFX2 endovascular repair system is a unibody, bifurcated stent graft that can be used in an abdominal aortic aneurysm associated with anatomical challenges, especially if it is combined with different aortic cuffs. The use of an AFX2 main body combined with a thoracic stent graft as a proximal aortic cuff was selected to treat a 77-year-old male patient with abdominal aortic aneurysm. The AFX2 endograft combined with a proximal thoracic aortic cuff plays a safe and effective role in treating complex infrarenal abdominal aortic aneurysm that may otherwise be technically more challenging with the open technique and inaccessible with the traditional endovascular technique.

Aneurysm sac shrinkage after endovascular treatment of the aorta: beyond sac pressure and endoleaks.

The isolation of the aneurysm sac from systemic pressure and its consequent shrinkage are considered criteria of success after endovascular repair (EVAR). However, the process of shrinkage does not solely depend on the intrasac pressure, the predictive role of which remains ambiguous. This brief review summarizes the additional pathophysiological mechanisms that regulate the biomechanical properties of the aneurysm wall and may interfere with the process of aneurysm sac shrinkage.

Open surgical repair of abdominal aortic aneurysm and horseshoe kidney: A strange relationship.

INTRODUCTION AND IMPORTANCE: The horseshoe kidney (HK) is the most common fusion defect of the kidneys. Τhe simultaneous presence of HK and abdominal aortic aneurysm (ΑΑΑ) is rare and comprises a technical challenge for the vascular surgeon due to variation of renal arteries and the renal isthmus overlying the AAA sac. CASE PRESENTATION: We present the first case in Nicosia General Hospital of Cyprus of an infrarenal AAA with a HK (Crawford Type I), which was successfully treated using an open surgical approach. CLINICAL DISCUSSION: Review the technical challenges associated with the case and a brief reference to the relevant published articles. CONCLUSION: The surgical repair of coexistence of AAA and HK continues to be a difficult technical challenge for the vascular surgeon from the past until today. There is a need to record the few cases and to create detailed specific guidelines to facilitate the surgical approach for the disease.

Ruptured true aneurysm of the superficial femoral artery leading to Behçet disease diagnosis.

Femoral artery aneurysms are rare, and aneurysms of the superficial femoral artery (SFA) are even rarer, with ruptured true aneurysms of the SFA the rarest. In the present report, we have described the case of a young patient whose SFA had clinical findings suggestive of an aneurysm rupture, which resulted in the diagnosis of Behçet disease, in accordance with the clinical features of the disease. The patient underwent standard treatment, with aneurysmectomy and interposition of a synthetic graft.

Early results of the Endurant endograft system in patients with friendly and hostile infrarenal abdominal aortic aneurysm anatomy.

OBJECTIVE: To evaluate and compare the outcome after endovascular abdominal aortic aneurysm repair (EVAR) with the newly released Endurant endograft system in patients with different aortoiliac anatomic characteristics. METHODS: We conducted a prospective observational study assigning patients with infrarenal abdominal aortic aneurysm (AAA) treated with the Endurant endoprosthesis from February 2009 to March 2010. Two groups were studied, according to the presence of a friendly (group I [GI] = 43) or hostile (group II [GII] = 34) infrarenal aortoiliac anatomy. Hostile profile was defined as any (or combination) of the following measurements: 5 mm ≤ proximal neck length (Lpr) ≤ 12 mm, 60° < proximal neck angle (A°pr) ≤ 90° and 60° < any iliac axis angle (A°iliac) ≤ 90°. Primary end points included technical and clinical success, freedom from early or late secondary interventions, any type of endoleak, and aneurysm-related death. All outcome measures were calculated using the Kaplan-Meier method and the log rank test was applied for comparisons between the groups. RESULTS: The mean comorbid severity scoring was higher in GII (P = .018). The mean follow-up period in GI and GII was 12.9 ± 3.9 months (± SD, range: 6.4-19.8) and 12.4 ± 4 months (range: 4.2-19.6), respectively. Two unplanned conversions to aortouniiliac configurations were required in GI. The technical success rate in GI and GII was 95.4% and 100%, respectively. The requirement for intentional occlusion of the internal iliac artery, the requirement for cross-limb technique, the necessity of troubleshooting techniques, the procedure and radiation times, the frequency of postimplantation syndrome, and mean hospital stay were significantly higher in GII (P = .028, P = .013, P = .005, P = .037, P < .001, P = .032, P = .021, respectively). Two patients of GI died in the early postoperative period (one aneurysm but not device-related death), whereas no deaths in GII were recorded, yielding an overall 30-day mortality rate of 2.3%. No type I/III endoleaks were recorded up to the end of the study. Freedom from any type of endoleak, early or late secondary interventions, and aneurysm-related death at 12 months were found in 93.2%, 87.1%, and 93.3% of GI patients; respective values for GII were 86% (P = .21), 93.4% (P = .066), and 93.4%. The clinical success rate was 82.1% and 100% at 12 months for GI and GII, respectively. CONCLUSIONS: Early (12 months) results suggest similar clinical performance of the Endurant stent graft system in endovascular treatment of AAAs with friendly and hostile anatomies, however, demonstrating more intra- and perioperative adversities for the last group. Larger prospective studies or even randomized trials comparing different new generation graft models are required to evaluate the comparable long-term results and possible expansion of EVAR indications for this specific endograft in adverse anatomies.

Emergency endovascular treatment of early spontaneous nonaneurysmal popliteal artery rupture in a patient with Salmonella bacteremia.

Rupture of a nonaneurysmal popliteal artery and subsequent pseudoaneurysm formation is an exceedingly rare event after bacteremia caused by Salmonella spp. Only a few cases have been reported in the literature. Moreover, spontaneous popliteal artery rupture resulting from this pathology, to our knowledge, has not been reported. We describe an early spontaneous rupture of the popliteal artery complicated by acute compartment syndrome in a 67-year-old man who had recently experienced fever, chills, and diarrheal syndrome and had sustained episodes of bacteremia infection, with isolation of S enteritidis. Immediate endovascular sealing of the bleeding site was achieved with a covered stent, and his recovery was uneventful. The long-term durability of endovascular repair in this type of pathology remains to be determined, however.

Giant Splenic Aneurysm with Arteriovenous (A-V) Shunt, Portal Hypertension, and Ascites.

BACKGROUND Splenic aneurysms are rare, asymptomatic, and usually derive from previous surgical interventions. Endovascular repair is the best option, but when A-V shunt is present, open repair might be more suitable. CASE REPORT A 43-year-old man presented to the Internal Medicine Department of AHEPA University Hospital with symptoms of fever and ascites. He was an ex-medical student with a history of sickle cell anemia, who had undergone urgent splenectomy and cholecystectomy 26 years ago and had a transit ischemic attack at the age of 21 years. Diagnostic imaging control revealed a giant splenic aneurysm 9.8 cm in diameter and 5 cm in length, with a concomitant A-V shunt (due to common ligation of the vessels after splenectomy and long stump presence with concomitant erosion of arterial wall). The patient underwent open surgery and cross-clamping the orifice of the splenic artery, also including the splenic vein, and the vessels were ligated. Post-operatively, the patient remained in the Intensive Care Unit for 48 h and suffered a portal vein thrombosis treated with appropriate anticoagulants. One month later, he had acute hemorrhagic pancreatitis and paralytic ileus and underwent laparotomy performed by general surgeons. CONCLUSIONS Giant splenic aneurysms are rare and are usually caused by previous splenectomy and preservation of a long-vessel stump. Immediate surgical repair is mandatory because of the high risk of rupture.

Percutaneous Endovascular Recanalization of a Thrombosed Aortic Graft Limb with Stent Placement.

Common practice in recanalization of a thrombosed prosthetic graft limb in an aortoiliac bypass focuses on balloon-catheter thrombectomy and angiographic exploration followed either by open surgical revision or endovascular management. This report describes the technique of percutaneous endovascular recanalization of an early thrombosed aortic graft limb with stent placement and subsequent restoration of patency and adequate limb perfusion, which remains patent after one year. Percutaneous intervention with stent placement and angioplasty for early graft limb recanalization avoids femoral incisions, and complications or morbidity associated with open surgery, while permitting rapid mobilization of the patient.

A computational study of the factors influencing pressure in arteriovenous fistulae venous aneurysms.

PURPOSE: To investigate the factors influencing the hydrostatic pressure exerted within the venous aneurysms (VA) of an arteriovenous fistula (AVF). METHODS: Ideal models of a side-to-end brachial-cephalic AVF were computationally constructed and typical values for the length and the local diameters were considered for both the artery and vein sections of the models. Three VA configurations were reconstructed (spherical, fusiform and curved) and hydrostatic pressure was assessed with respect to different degrees of the outflow vein stenosis, ranging from 25% to 95%, and VA maximum diameters, using validated, commercially available software. RESULTS: The pressure in the VA was steady (1200 Pa) for venous outflow stenoses up to 75%. For stenoses greater than 75% a exponential pressure rise was observed, reaching 1500 Pa for stenoses of 95%. Neither the VA configuration nor its maximum diameter affected the pressure values exerted within the VA or the point of the pressure upstroke. CONCLUSIONS: our study supports the presence of a critical stenotic outflow vein diameter beyond which there is an exponential VA pressure increase, influenced neither by the shape nor the size of the VA. Whether the prompt, non-invasive detection of this finding can contribute or lead to the determination of a criterion for early intervention in VAs before clinical complications are developed, should be investigated by future studies.

An uncommon clinical presentation of acute limb ischemia: underscoring the role of perigenicular collaterals.

We present a case of atypical acute limb ischemia in a non-diabetic patient, with ankle-brachial pressure index of 0.6 and rest pain localized exclusively over the gastrocnemius muscle, sparing the foot. This uncommon presentation was attributed to an impaired perigenicular collateral network. Thrombolysis restored adequate perfusion only temporarily and was followed by thromboembolectomy. The ischemia presentation in our case underscores the importance of the adequacy of the perigeniculate collateral network for the perfusion of the tibial muscles and, especially, the gastrocnemius muscle.

Modification of the trap door technique to treat venous aneurysms in arteriovenous fistulae.

We present a modification of the "trap door" technique to treat true venous aneurysms which complicate vascular access arteriovenous fistula. The technique provides wide exposure of the aneurysm, facilitating aneurysmoraphy and permitting the exploitation of any adequate venous length for autologous reconstruction of the venous outflow. Furthermore, by precluding the proximity of the newly-reconstructed venous segments to the incised skin, their level of compromise from tissue scarring or infection is prevented.

Technical advances with newer aortic endografts provide additional support to withhold the early endovascular repair of small abdominal aortic aneurysms until it is really needed.

The idea of early endovascular aortic repair (EVAR) of "small" abdominal aortic aneurysms (AAAs) has gained attention over "watchful waiting," mostly due to the concern for losing the anatomic suitability for endovascular repair over time. Generally, small AAAs have longer, smaller, less angulated necks, and less tortuous iliac arteries than larger ones. Though the borderline anatomic characteristics were assumed to be contraindications for older generation endografts, the modifications of modern devices seem promising to overcome those limitations, in order to treat the small AAAs when reaching the 5.5 cm threshold. Moreover, early endovascular intervention has been proven neither cost effective nor beneficial for the patients' quality of life. This article evaluates the technical progress that could overcome the difficulties of those small AAAs that present technically demanding anatomies, thus advocating endovascular intervention when they reach the diameter threshold.

Application of bioengineering modalities in vascular research: evaluating the clinical gain.

Using knowledge gained from bioengineering studies, current vascular research focuses on the delineation of the natural history and risk assessment of clinical vascular entities with significant morbidity and mortality, making the development of new, more accurate predictive criteria a great challenge. Additionally, conclusions derived from computational simulation studies have enabled the improvement and modification of many biotechnology products that are used routinely in the treatment of vascular diseases. This review highlights the promising role of the bioengineering applications in the vascular field.