Iliac tortuosity increases reinterventions but not adverse outcomes following repair of juxtarenal aneurysms using physician-modified endografts.

OBJECTIVE: Increased angulation of the proximal aortic neck has been associated with complications following endovascular repair of infrarenal aortic aneurysms, including increased incidence of endoleaks, stent migration, secondary interventions, and conversions. However, knowledge on the impact of aortoiliac tortuosity on outcomes following fenestrated repair remains limited. This study aims to quantify the effect of aortoiliac tortuosity on outcomes following fenestrated repair. METHODS: A single-center, retrospective review of all patients who underwent a physician-modified endovascular repair for the treatment of juxtarenal aortic aneurysms under a single physician-sponsored investigation device exemption study from 2011 to 2021 was performed. Center luminal lines and geometric distances were obtained using TeraRecon software (San Mateo, CA). A tortuosity index was calculated (tortuosity index = centerline distance/geometric line distance) for each iliac vessel as well as for the infrarenal aorta according to Society for Vascular Surgery reporting standards. Aortic and iliac tortuosity were assessed independently and stratified as low and high. Demographics, comorbidities, anatomic and operative details, and outcomes were compared using univariable and multivariable analysis. RESULTS: A total of 135 patients were identified. Thirty-eight patients (28%) had high aortic tortuosity, and 55 patients (42%) had high iliac tortuosity. Patients with high tortuosity were older (aortic: 78 vs 76 years; P = .04; iliac: 78 vs 75 years; P = .01) and differed by sex. Twenty-two percent of men and 50% of women had high aortic tortuosity (P = .01). Forty-seven percent of men and 20% of women had high iliac tortuosity (P = .01). There were no differences in comorbidities based on aortic tortuosity, but coronary artery disease (high: 58% vs low: 36%; P = .01) and hypertension (high: 69% vs low: 86%; P = .02) differed based on iliac tortuosity. Aneurysm diameter was larger for patients with high iliac tortuosity (72 mm vs 64 mm; P < .01), and fluoroscopy time was longer for patients with high aortic tortuosity (41 vs 31 minutes; P = .02). When outcomes were assessed, high iliac tortuosity was associated with increased rate of reinterventions (hazard ratio, 2.6; 95% confidence interval, 1.2-6.0) and type 1 or 3 endoleak (hazard ratio, 5.2; 95% confidence interval, 1.7-16); however, all other outcomes were similar. CONCLUSIONS: Among patients treated with physician-modified endovascular repair for juxtarenal aneurysms, iliac tortuosity but not aortic tortuosity, is associated with increased reinterventions and type 1 or type 3 endoleaks. Long-term follow-up is critical for patients with high iliac tortuosity to ensure that high-risk endoleaks are identified and treated early to avoid the risk of rupture.

Systematic review of risk factors and outcomes of post-implantation syndrome following endovascular aortic repair.

OBJECTIVE: Post implantation syndrome (PIS) is an early systemic inflammatory response following endovascular aortic repair (EVAR). The response is variable in patients and the clinical significance of PIS upon outcomes is unknown. This study aims to evaluate the incidence, risk factors, and prognostic implication of PIS. METHODS: Systematic literature review and analysis was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and Cochrane guidelines of PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. Eligible English-language studies regarding PIS after infrarenal EVAR were included, after removing duplicates. RESULTS: After screening, 31 studies were included. A total of 2847 patients were reviewed, with mean age of 70.7 years, of which 2012 (90.4%) were male, with a pooled mean follow-up of 26.1 months. PIS was reported in 25.3% of cases, with mean aneurysm diameter of 56.4 cm. Polytetrafluoroethylene (PTFE) grafts were utilized in 794 patients (27.9%) with polyester in 1839 (64.6%). White blood cell count, C-reactive protein, interleukin (IL)-6, IL-8, and IL-10 levels were all significantly elevated postoperatively. Thirty-day outcomes included type I endoleak rate of 0.8%, type II endoleak rate of 1.7%, reintervention rate of 0.35%, and mortality rate of 0.25%. Subgroup pooled analysis of patients with PIS (n = 309) vs No-PIS (n = 691) revealed that polyester (n = 642), rather than PTFE (n = 234) grafts, were associated with a higher rate of PIS (94.8% vs 3.7%; P = .0001), White blood cell count was higher in the PIS group both preoperatively (7.61 vs 6.76 × 109/L; P = .04) and postoperatively (15.0 vs 9.8 × 109/L; P = .0007) and IL-6 levels were higher in the PIS group postoperatively (98.6 vs 25.2 pg/mL; P = .02). Aneurysm diameter and amount of chronic or new thrombus within the aneurysm sac was not identified as a risk factor for PIS. Pooled outcomes of patients with PIS vs No-PIS demonstrated a significantly higher rate of 30-day mortality (0.6% vs 0%; P = .03) and major adverse cardiac events (5.8% vs 0.43%; P < .0001) without any differences seen in reintervention or 30-day type I or type II endoleaks. CONCLUSIONS: This systematic review suggests that polyester grafts are strongly associated with PIS compared with PTFE. Interestingly, this report is suggestive of an association between 30-day mortality and major adverse cardiac events and PIS. Given these clinical sequelae, consideration for use of PTFE over polyester grafts to reduce the incidence of PIS may be a simple step to improve overall outcome. Further, exploration of the relationship between inflammatory mediators associated with PIS and mortality and cardiac complications may engender deeper understanding of risks, leading to eventual mitigation of harm for patients experiencing PIS.

[Late Open Semi-conversion with Endograft Preservation for (Type II) Endoleaks with Late Aneurysm Sac Enlargement after EVAR - Indications, Method and Results in Our Own Patient Collective]. / Die späte offene Semikonversion mit Prothesenerhalt bei (Typ II­)Endoleckagen mit spätem Aneurysmasackwachstum nach EVAR - Indikationen, Methode und Ergebnisse im eigenen Patientenkollektiv.

EVAR (endovascular aortic repair) is the most common method for treating an abdominal aortic aneurysm, but according to the latest findings it carries the risk of subsequent complications. These can be caused by (late) aneurysm sac growth. If conservative and surgical therapies fail to treat the aneurysm sac growth, open conversion is necessary to prevent aneurysm rupture. There are several options for open conversion, in which the EVAR prosthesis can be completely preserved or is (partially) removed. Late open semi-conversion with complete in-situ preservation of the EVAR-prosthesis and gathering of the aneurysm sac are a less invasive method than complete conversion and may be performed instead for selected patients. The aim of the present work is to present the surgical method, including indications and technical information, as well as the presentation of the results in our recent patient collective.All patients semi-converted in our department of vascular surgery and phlebology due to (type II) endoleak were included. All data are presented as n (%) or median (range).Between 6/2019 and 3/2023, 13 patients underwent semi-conversion 6 (2-12) years (median, range) after the initial EVAR. The aneurysm sac diameter at the time of semi-conversion was 69 mm (58-95 mm), the operating time was 114 min (97-147 min), the blood loss was 100 ml (100-1500 ml). Five (38%) patients received blood transfusion intraoperatively and 2 (15%) postoperatively. The stay in the intensive care unit lasted 1 (1-5) days, the hospitalisation time was 8 (6-11) days. Postoperative complications were intestinal atony (3 [23%], 1 [8%] with nausea/emesis and gastric tube insertion), anaemia (2 [15%]), hyponatraemia (2 [15%]), delirium (1 [8%]), COVID-19 infection (1 [8%]) and 1 [8%] intra-abdominal postoperative bleeding with the indication for surgical revision and the transfusion of 8 erythrocyte concentrates.Semi-conversion is a safe and practicable surgical method with few severe complications for a selected group of patients, which should be considered as an alternative to more invasive methods with (partial) removal of the EVAR-prosthesis. Further long-term studies comparing semi-conversion to full conversion are needed to demonstrate its benefits.

Preliminary results from an Italian National Registry on the outcomes of the Najuta fenestrated aortic arch endograft.

BACKGROUND: Arch pathology represents one of the last frontiers in aortic aneurysm endovascular management. Several companies recently developed dedicated branched and fenestrated endografts specifically designed for the aortic arch, aiming to overcome some of the issues associated with standard thoracic endograft and supra-aortic vessels extra-anatomic debranching. This study aimed to evaluate early outcomes obtained with a custom-made fenestrated endograft approved for thoracic aortic aneurysms exclusion. METHODS: All consecutive patients treated with the Najuta endograft (Kawasumi Laboratories, Inc, Tokyo, Japan) in Italy were enrolled prospectively and included in the study population. Anatomic characteristics and perioperative data were analyzed retrospectively. Study end points were technical success, 30-day clinical success, overall survival, supra-aortic vessel patency, endoleak, and need for reintervention or surgical conversion. RESULTS: Between 2018 and 2022, 76 patients received a Najuta endograft in Italy and were enrolled in the study. The median patient age was 72 years (interquartile range, 69-76 years) and 80.3% were male. Most of the patients received treatment for atherosclerotic aneurysms (80.3%); others were treated for postdissection aneurysms (7.9%), penetrating aortic ulcer (9.2%), or type I endoleak correction after previous thoracic endovascular repair (2.6%). Overall, 161 supra-aortic vessels were preserved through a dedicated fenestration. Technical success was achieved in 74 of 76 procedure (97.4%); both failures were associated with endoleak detection at final angiography (one type I and one type III endoleak). Two distal migrations occurred during the implanting procedure. Clinical success at 30 days was 94.7%. Two early reinterventions were needed within 30 days after index procedure: in one case, an aortic false lumen coils embolization was performed, because distal re-entry caused enlargement of the postdissection thoracic aneurysm. The other procedure consisted of a femoral pseudoaneurysm repair. The median follow-up was 7 months (interquartile range, 3-15 months); no supra-aortic vessel occlusions occurred and no patients needed surgical conversion. CONCLUSIONS: Early results suggest that, in selected patients with aortic arch pathology needing a proximal landing, an endovascular approach with the Najuta system is safe and effective, especially for those at high surgical risk. A strict follow-up with high-quality computed tomography angiography images and eventual evaluation for long-term complications is needed to confirm these initial experience findings.

A systematic review of open, hybrid, and endovascular repair of aberrant subclavian artery and Kommerell's diverticulum treatment.

BACKGROUND: Aberrant subclavian artery (AScA) with or without associated Kommerell's diverticulum (KD) is the most frequently encountered anomaly of the aortic arch, it may be life threatening, especially when associated with aneurysmal degeneration. The best management is still debated and depends on many clinical and anatomical factors. A systematic review was conducted to assess the current evidence on the treatment options and their efficacy and safety for AscA and KD repairs. METHODS: A literature search in PubMed and Cochrane Library was performed, and articles that were published from January 1947 to August 2021 reporting on AscA and KD management were identified. Multicenter studies, single-center series, and case series with three or more patients were considered eligible in the present review. A comparison of outcomes of patients who underwent open surgery (OS), a hybrid approach (HA), and total endovascular repair (ER) (ie, 30-day mortality and stroke were analyzed when available and compared among the three groups (P < .05; Benjamini and Hochberg-adjusted P < .05; Bonferroni-adjusted P < .05). Titles, abstracts, and full texts were evaluated by two authors independently. Primary outcomes included survival rate, perioperative stroke, arm ischemia, and spinal cord ischemia. Endoleak, in the case of HA and ER, and reintervention rates were considered outcomes. RESULTS: Three hundred thirty-one articles were initially evaluated and 30 studies, totaling 426 patients treated for AScA with 324 KD, were included. Of the 426 patients, 241 were male (56.5%), and the mean patient age was 57.9 ± 12.0 years. The approach was OS in 228 patients, HA in 147 patients, and ER in 51. Dysphagia was the most common presentation in 133 cases. Aortic rupture was observed in 16 of the 426 patients (3.8%), including 14 AScA/KD (3.3%) aneurysm rupture. KD maximum diameter varied widely from 12.6 to 63.6 mm. The overall 30-day mortality was 20 (4.7%) (OS group 8/228 [3.5%]; HA group 10/147 [6.8%]; ER 2/51 [3.9%]; P = NS). The overall stroke rate was 4.9% (21/426) (OS group 10/228 [4.4%]; HA group 6/147 [4.1%]; ER group 5/51 [9.8%]; P = NS), including nine transient and nondisabling neurological deficits. Overall secondary procedures for complications were reported in 36 of the 426 cases (8.4%), mostly owing to endoleak. Follow-up varied from 13 to 74 months. CONCLUSIONS: This systematic review assessed the current outcomes of the three types of therapeutic management for AScA and KD and demonstrated that they are all relatively safe and effective, providing satisfactory early and midterm outcomes. Long-term outcomes are warranted, especially for total ERs since the long-term durability of stent grafts remains unknown.

Endovascular repair combined with adjunctive procedures in the treatment of tuberculous infected native aortic aneurysms.

OBJECTIVE: The present study aimed to analyze the experience of a single center and assess the efficacy and durability of endovascular aortic repair (EVAR) in patients with tuberculous infected native aortic aneurysms (INAAs). METHODS: All patients who underwent EVAR for INAAs between September 2014 and August 2021 were reviewed retrospectively. The primary end points were 30-day and overall mortality rates; the secondary outcomes included major complications, endoleak, recurrence, reintervention rate, and thrombosis of the pseudoaneurysmal sac. RESULTS: A total of 18 patients (average age, 61.3 years; 10 female [55.6%]) were identified. Fifteen patients (83.3%) had adjunctive procedures. Both the in-hospital and 30-day mortality rates were 0%. The overall cumulative survival rates estimated by Kaplan-Meier were 100% at 1 and 6 months, and 92.3% at 12 and 24 months, and 80.8% at 36 and 48 months. Type Ib and II endoleaks each occurred in 1 patient (5.6%) and resolved without treatment after 1 month. No graft infections, strokes, paraplegia, ischemic abdominal complications, or other major complications occurred. The overall rates of cumulative freedom from recurrence of aneurysm and reintervention were 83.9% and 81.8%, respectively, during the median follow-up period of 28.5 months (range, 1-72 months). The median time of administering antituberculosis drugs was 10.5 months (range, 2-44 months). CONCLUSIONS: EVAR combined with oral antituberculosis medication is effective and may be an appealing treatment option for patients with high-risk INAAs. Adjunctive procedures, including targeted drug delivery to the site of infection, could be a solution to further controlling the infection, but still needs further evaluation.

Incidence of stent graft failure from type IIIB endoleak in contemporary endovascular abdominal aortic aneurysm repair.

BACKGROUND: Type IIIB endoleak from material failure can lead to aneurysmal sac enlargement and latent rupture after endovascular repair of abdominal aortic aneurysm. Long-term durability of the endovascular stent graft is largely unknown, and the complication rate from device failure due to material fatigue may be underappreciated. In addition, even with advancement in imaging techniques, recognition of type IIIB endoleak can be challenging, which can lead to delay in intervention. METHODS: A review of the literature was performed in PubMed and Google Scholar, yielding 23 articles with 46 case reports of type IIIB endoleak from various Food and Drug Administration-approved stent grafts after endovascular repair of infrarenal abdominal aortic aneurysm. RESULTS: The most common location of type IIIB endoleak occurred in the main body (34.8%), followed by the area of the flow divider (32.6%). Sac growth was identified in 63% (29/46) of cases. Diagnosis of the endoleak occurred an average of 54.3 months after the index operation. Endovascular repair was the primary approach for elective repair of type IIIB endoleak (61.3% vs 13.3%). Perioperative mortality was higher in ruptured or symptomatic patients compared with patients undergoing elective repair (33.3% vs 6.5%). CONCLUSIONS: The actual incidence of type IIIB endoleak is still lacking, and the etiology may be multifactorial. Therefore, suspicion of type IIIB endoleak requires appropriate imaging techniques and prompt intervention to reduce the perioperative mortality rate.

Spontaneous intracerebral haemorrhage: a rare complication of aortic aneurysm endoleak.

We present a rare case of intracerebral haemorrhage secondary to consumptive coagulopathy in relation to ongoing endoleak after thoracic endovascular aneurysm repair (TEVAR). A 68-year-old man underwent elective TEVAR for an 18 cm diameter Crawford type II thoracoabdominal aneurysm. He was subsequently shown to have a type 1b endoleak and a short episode of disseminated intravascularcoagulation (DIC) perioperatively. Two months after the procedure, he experienced a consumptive coagulopathy leading to intracerebral haemorrhage and ultimately his death. Endoleak-related DIC is an underappreciated phenomenon within the medical literature. Currently, management is reliant on general DIC principles and anecdotal experiences of others within the case report literature.

Fitness plus American Society of Anesthesiologists grade improve outcome prediction after endovascular aneurysm repair.

BACKGROUND: Although the American Society of Anesthesiologists (ASA) grade was established for statistical purposes, it is often used prognostically. However, older patients undergoing elective surgery are typically ASA III, which limits patient stratification. We look at the prognostic effect on early complications and survival of using ASA and self-reported physical fitness to stratify patients undergoing endovascular repair of abdominal aortic aneurysms. METHODS: Data were extracted from a trial database. All patients were assigned a fitness level (A (fit) or B (unfit)) based on their self-reported ability to walk briskly for 1 km or climb two flights of stairs. Fitness was used to stratify ASA III patients, with fitter patients assigned ASA IIIA and less fit patients ASA IIIB. Outcomes assessed included survival, reinterventions, endoleak, all early and late complications and early operative complications. RESULTS: A combined ASA/fitness scale (II, IIIA, IIIB and IV) correlated with 1- and 3-year survival (1-year P = 0.001, 3-year P = 0.001) and early and late complications (P = 0.001 and P = 0.05). On its own, ASA predicted early complications (P = 0.0004) and survival (1-year P = 0.01, 3-year P = 0.01). Fitness alone was predictive for survival (1-year P = 0.001, 3-year P = 0.001) and late complications (P = 0.009). CONCLUSION: This study shows that even a superficial assessment of fitness is reflected in surgical outcomes, with fitter ASA III patients showing survival patterns similar to ASA II patients. Physicians should be alert to differences in fitness between patients in the ASA III group, despite similarities based on preexisting severe systemic disease.

Evidence for Ethylene-Vinyl-Alcohol-Copolymer Liquid Embolic Agent as a Monotherapy in Treatment of Endoleaks.

OBJECTIVE: Endoleak remains the Achilles heel of endovascular aneurysm repair and the exclusion of Type II endoleaks, in particular, remains challenging. This systematic review presents the evidence for ethylene-vinyl-alcohol-copolymer liquid embolic agent as a monotherapy in the treatment of endoleaks. METHODS: A systematic literature search was performed for all studies reporting the use of liquid embolic agent as a sole agent in the treatment of endoleaks. Patient numbers, clinical details (endoleak type, route of delivery) and outcome in terms of survival, technical and clinical success with freedom from endoleak together with follow-up period were examined. RESULTS: Only 12 articles reporting the use of liquid embolic as the sole treatment modality for endoleaks in 174 patients were identified. All but 21 patients had a Type II endoleak. Transarterial embolization was attempted in 73% of patients with 48 patients having direct sac puncture. Technical success was high at 96%, but in patients with adequate imaging, the clinical success rate dropped to 79%. Complications were sparsely reported and follow-up ranged from 0 to 75 months. CONCLUSIONS: This review highlights the lack of data regarding the use of liquid embolic agent as a monotherapy with only 4 studies including more than 10 patients. Data from the largest series suggests a learning curve exists and no study reports on cost effectiveness. Technical success does not always translate into clinical success and with the largest series only reporting median 4-month follow-up no claims regarding durability can be made. In problematic Type II endoleaks, however, liquid embolic agent is a welcome addition to the treatment armamentarium.

Systemic Inflammatory Disease and Its Association With Type II Endoleak and Late Interventions After Endovascular Aneurysm Repair.

IMPORTANCE: Abdominal aortic aneurysms are associated with chronic inflammation within the aortic wall, and previous studies have suggested that chronic inflammation may be a consequence of a dysregulated and persistent autoimmune response. Persistent aortic remodeling after aneurysm repair could place the patient at risk for endoleak or sac rupture. OBJECTIVE: To determine whether patients with systemic inflammatory disease and large aneurysms have persistent aortic remodeling after endovascular aneurysm repair (EVAR). DESIGN, SETTING, AND PARTICIPANTS: The records of all patients who underwent EVAR between July 2002 and June 2011 at the Veterans Affairs Connecticut Healthcare System were included in this retrospective review. Patients were considered to have a systemic inflammatory disease when confirmed by a referring specialist. Post-EVAR surveillance was performed by yearly imaging. INTERVENTION: Endovascular aneurysm repair. MAIN OUTCOMES AND MEASURES: Significant endoleak, defined as endoleak and sac diameter increase of 0.5 cm or greater. RESULTS: A total of 51 of 79 patients (65%) had a systemic inflammatory disease. These patients had similar comorbid conditions compared with patients without inflammation but significantly greater numbers of major postoperative complications after EVAR (23.5% vs 3.6%; P = .02) and overall postoperative complications after EVAR (27.5% vs 7.1%; P = .03). Patients with a history of systemic inflammatory disease developed more endoleaks (45.1% vs 17.9%; P = .02) and late sac expansion (51.0% vs 21.4%; P = .01) and required more interventions (21.6% vs 3.6%; P = .03) during long-term follow-up. Systemic inflammatory disease was significantly associated with significant endoleak (odds ratio, 5.18; 95% CI, 1.56-17.16; P = .007). CONCLUSIONS AND RELEVANCE: Patients with systemic inflammatory disease are at high risk for postoperative complications, type II endoleak, sac expansion, and additional interventions after EVAR. Additional strategies for improving the efficacy of EVAR in these patients may be warranted.

[Outcomes of endovascular repairing aortic arch disease hybrid with supra-arch debranching procedures].

OBJECTIVE: To summarize the experience of endovascular repairing aortic arch disease hybrid with supra-arch debranching procedures. METHODS: It was a retrospective study. From January 2002 to December 2014, 42 high risk patients with aortic arch disease were treated by supra-arch debranching hybrid with subsequent endovascular repair in the First Affiliated Hospital of Sun Yat-sen University. There were 39 male and 3 female patients with a mean age of (53±13) years (ranging from 34 to 80 years). Of the 42 patients, 7 were thoracic aortic aneurysm, 20 were Stanford type B aortic dissection and 15 were Stanford type A aortic dissection. After the supra-aortic debranching technique, simultaneous (n=16) or staged (n=26, mean interval (7±3) days) endovascular repair were performed. Fisher exact test was used to compare the in-hospital mortality of ascending aorta based debranching and non-ascending aorta based debranching. RESULTS: Technical success rate was 81.0% (34/42). The overall 30-day complication rate was 31.0% (13/42), including 3 cerebral stroke (7.1%), 8 endoleak (19.0%, including 6 type I endoleak and 2 type II endoleak), 1 circulatory failure, 1 aorto-tracheal fistula. The 30-day mortality was 9.5% (4/42), 2 died of cerebral stroke, 1 died of circulatory failure, 1 died of aorto-tracheal fistula. The in-hospital mortality of ascending aorta based debranching group was obviously higher than that of the non-ascending aorta based debranching group (4/16 vs. 0, P=0.02). The median time of follow-up was 64.8 (2 to 156.9) months. CT scanning was performed at 1, 3 months after surgery and annually thereafter. The overall survival rate was 76.6%. During the follow-up period, there was 4 deaths, and 2 of them were aortic artery related (5.3%). There were 4 de novo complications during the follow-up period, 1 stroke attributed to bypass occlusion was cured by medical treatment, 2 pseudoaneurysm was successfully treated with open surgery, 1 stent-graft induced new distal entry tear was successfully treated with a tapered stent-graft, there was no new endoleak during follow up period, 3 type I endoleak disappeared spontaneously, and 1 type II endoleak disappeared after secondary intervention. CONCLUSIONS: Endovascular repair of aortic arch disease hybrid with supra-arch debranching procedure is low invasive with favorable long-term outcomes. It is suitable for high risk patients of poor general condition with little tolerance to aortic arch replacement. The in-hospital mortality is higher in the ascending aorta based debranching group than in the non-ascending aorta based debranching group. Stroke is a critical fatal complication and should be attached attention.

Post evar endovascular revision of late onset stent graft collapse due to type 1 endoleak in a complicated case with left limb occlusion and solitary kidney.

Type 1 endoleak is one of the most frequent complication usually seen at the initial phase of EVAR procedure. Balloon dilatation is mostly used to oversize the proximal or the distal part of the orifice to stabilize the attachment of the graft stent to the aortic wall. Late onset of type 1 endoleak with graft stents may cause severe lumen compression of the stent and aneurysm enlargement which might cause a serious problem especially in a patient whose graft stents left iliac branch is thrombosed and the left leg is supplied by the bypass graft from right CFA. Although operation was advised by the endovascular specialists the procedure was done in our hospital as the patient preferred the endovascular method instead of open surgery.

Management of AAA and late Type II EL in a patient with concomitant renal cell carcinoma. Report of a case and review of the literature.

PURPOSE: Detection of cancer in patients with AAA complicates the treatment of both diseases. AAA associated with RN are rare, with an incidence of 0.1-3% representing a challenge in defining the surgical timing and approach. We discuss the rational for the treatment in patients with concomitant patologies. CASE REPORT: A 65 years-old man was diagnosed with both AAA and Renal Cell Carcinoma. The patient underwent first EVAR followed by renal embolization and Radical Nefrectomy. Three months later a Type II Endoleak was diagnosed and treated successfully. At 1 year follow-up the patient is disease free with complete exclusion of aneurysm sac. CONCLUSION: AAA can be successfully repaired in patients with renal neoplasm with great results, either simultaneously or in two stages. EVAR is a good alternative for such complex patients.

Treatment of post-implantation aneurysm growth by laparoscopic sac fenestration: long-term results.

OBJECTIVES: Sac growth after endovascular aneurysm repair (EVAR) is an important finding, which may influence prognosis. In case of a type II endoleak or endotension, clipping of side branches and subsequent sac fenestration has been presented as a therapeutic alternative. The long-term clinical efficacy of this procedure is unknown. METHODS: The study included eight patients who underwent laparoscopic aortic collateral clipping and sac fenestration for enlarging aneurysms following EVAR. Secondary interventions and clinical outcome were retrieved from hospital records. Sac behaviour was evaluated measuring volumes on periodical computed tomography angiography (CTA) imaging using dedicated software. RESULTS: Follow-up had a median length of 6.6 (range 0.6-8.6) years. During this time, only three patients successfully achieved durable aneurysm shrinkage (n = 2) or stability (n = 1). The remaining patients suffered persistent (n = 2) or recurrent sac growth (n = 3), all regarded as failure of fenestration. A total of six additional interventions were performed, comprising open conversion (n = 2), relining (n = 1) and implantation of iliac extensions (n = 3). All additional interventions were successful at arresting further sac growth during the remainder of follow-up. CONCLUSIONS: Despite being a less invasive alternative to conversion and open repair, the long-term outcome of sac fenestration is unpredictable and additional major procedures were often necessary to arrest sac growth.