Image-based assessment of aortoiliac aneurysm anatomical characteristics in patients from the global iliac branch study.

OBJECTIVE: Endovascular repair is the preferred treatment for aortoiliac aneurysm, with preservation of at least one internal iliac artery recommended. This study aimed to assess pre-endovascular repair anatomical characteristics of aortoiliac aneurysm in patients from the Global Iliac Branch Study (GIBS, NCT05607277) to enhance selection criteria for iliac branch devices (IBD) and improve long-term outcomes. METHODS: Pre-treatment CT scans of 297 GIBS patients undergoing endovascular aneurysm repair were analyzed. Measurements included total iliac artery length, common iliac artery length, tortuosity index, common iliac artery splay angle, internal iliac artery stenosis, calcification score, and diameters in the device's landing zone. Statistical tests assessed differences in anatomical measurements and IBD-mediated internal iliac artery preservation. RESULTS: Left total iliac artery length was shorter than right (6.7 mm, P = .0019); right common iliac artery less tortuous (P = .0145). Males exhibited greater tortuosity in the left total iliac artery (P = .0475) and larger diameter in left internal iliac artery's landing zone (P = .0453). Preservation was more common on right (158 unilateral, 34 bilateral) than left (105 unilateral, 34 bilateral). There were 192 right-sided and 139 left-sided IBDs, with 318 IBDs in males and 13 in females. CONCLUSION: This study provides comprehensive pre-treatment iliac anatomy analysis in patients undergoing endovascular repair with IBDs, highlighting differences between sides and sexes. These findings could refine patient selection for IBD placement, potentially enhancing outcomes in aortoiliac aneurysm treatment. However, the limited number of females in the study underscores the need for further research to generalize findings across genders.

Outcomes and Economic Impact of Hypogastric Artery Management During Elective Endovascular Aortic Repair for Aorto-Iliac Aneurysms.

BACKGROUND: To analyze clinical outcomes and perform a macro-costing evaluation of endovascular aortic repair (EVAR) for aorto-iliac aneurysms. METHODS: This is a retrospective, financially unsupported, physician-initiated observational cohort study. Patients with iliac artery involvement treated with EVAR between January 1st, 2014 and December 31st, 2021 were identified. Inclusion criteria were intact aneurysm, elective EVAR with at least 1 hypogastric artery (HA) treatment, use of bifurcated endograft (EG), and at least 6 months of follow-up. Primary outcomes of interest were overall survival, freedom from aneurysm-related mortality (ARM), freedom from EVAR-related reintervention, and overall EVAR(procedure)-related costs. RESULTS: We studied 122 (9.1%) patients: 119 (97.5%) were male and 3 (2.5%) females. Median age of patients was 76 years (range, 68.75-81). Overall, 107 (87.7%) patients had both HAs preserved according to following strategy: 45 (36.9%) with flared limbs, 13 (10.6%) with bilateral branched device, and 49 (40.2%) with a combination of flared limb on 1 side and branched device on the contralateral side. Bilateral overstenting was performed in 15 (12.3%) patients. Estimated overall survival was not different between groups of EVAR (Log-rank, P = 0.561). There was only 1 (0.8%) ARM ascertained during the follow-up. Estimated freedom from EVAR-related reintervention was not different among groups (Log-rank, P = 0.464). During the follow-up, 9 (7.4%) patients developed buttock claudication (Society for Vascular Surgery (SVS) grade 1, n = 4, SVS grade 2, n = 5), more frequently in HA overstenting (hazard ratio (HR): 3.6; 95% confidence intervals (CIs): 0.96-13.5, P = 0.058). When all cots were included, branched EVAR still carried the highest burden (P = 0.001) in comparison with the mixed subgroup, the overstenting subgroup, and the flared limbs subgroup. CONCLUSIONS: Early mortality and pelvic ischemic syndromes rate were acceptably low in all techniques. Hypogastric artery preservation showed lower complication rate in comparison with HA overstenting which, however, appears to be safe an effective for option with similar overall costs for patients who are not candidates for HA preservation based on aortic anatomy.

Compensated Patient Injuries in the Treatment of Abdominal Aortic and Iliac Artery Aneurysms in Finland: A Nationwide Patient Insurance Registry Study.

OBJECTIVES: Patient injury claims data and insurance records provide detailed information on patient injuries. This study aimed to identify the errors and adverse events that led to patient injuries in vascular surgery for the treatments of abdominal aortic aneurysms (AAA) and iliac artery aneurysms (IAA) in Finland. The study also assessed the severity and preventability of the injuries. MATERIALS AND METHODS: A retrospective analysis of Finnish Patient Insurance Centre's insurance charts of compensated patient injuries in the treatment of AAA and IAA. Records of all compensated patient injury claims involving AAA and IAA between 2004 and 2017 inclusive were reviewed. Contributing factors to injury were identified and classified. The injuries were assessed for their preventability by using the WHO Surgical Safety Checklist correctly. The degree of harm was graded by Clavien-Dindo classification. RESULTS: Twenty-six patient injury incidents were identified in the treatment of 23 patients. Typical injuries involved delays in diagnosis or treatment, errors in surgical technique or injuries to adjacent anatomic organs. Three (13.0%) patients died due to patient injury. Two deaths were caused by delays in diagnosis of ruptured abdominal aortic aneurysm (RAAA) and the third death was due to missed diagnosis of post-operative myocardial infarction. Retained foreign material caused injuries to two (8.7%) patients. One (4.3%) patient had a severe postoperative infection. Three (13.0%) patients experienced an injury to an adjacent organ. One patient had a bilateral and another a unilateral above-the-knee amputation due to patient injury. Three injuries were considered preventable. Most harms were grade IIIb Clavien-Dindo classification in which injured patients required a surgical intervention under general anesthesia. CONCLUSIONS: Compensated patient injuries involving the treatment of AAA and IAA are rare, but are often serious. Injuries were identified during all stages of care. Most injuries involved open surgical procedures.

Incidence and management of iliac artery aneurysms associated with endovascular treatment of juxtarenal and thoracoabdominal aortic aneurysms.

BACKGROUND: This study reports the clinical impact of iliac artery aneurysms (IAAs) in a population of patients with juxtarenal and thoracoabdominal aortic aneurysms being treated with fenestrated or branched aortic endografts. METHODS: Data from 364 patients with IAA (33%) were extracted from the 1118 patients treated for juxtarenal or thoracoabdominal aortic aneurysms with a fenestrated or branched aortic endograft in a physician-sponsored investigational device exemption trial (2001-2016). IAAs were defined as ≥21 mm in diameter, as measured by an imaging core laboratory. Outcomes were assessed by univariate and multivariable analysis. RESULTS: IAAs were unilateral in 219 (60%) and bilateral in 145 (40%) of the 364 patients. Treatment was iliac leg endoprosthesis without coverage of the hypogastric artery (seal distal to the IAA in the common iliac artery), placement of a hypogastric branched endograft in 105 (21%), and hypogastric artery coverage with extension into the external iliac artery in 103 (20%); 67 (13%) were untreated. Procedure duration was longer for those with IAA (5.3 ± 1.79 hours vs 4.6 ± 1.74 hours; P < .001), although hospital stay was not. There was no difference in aneurysm-related mortality and all-cause mortality for patients with unilateral and bilateral IAAs compared with those without an IAA. Treatment of patients with a hypogastric branched endograft had similar all-cause mortality compared with treatment of patients without a hypogastric branched endograft but also with an IAA. Reintervention rates were significantly higher in those with bilateral IAAs compared with no IAA (hazard ratio, 1.886; P < .001). Spinal cord ischemia trended higher in patients with bilateral IAA. CONCLUSIONS: IAA management at the time of fenestrated or branched endovascular aneurysm repair increases procedure time without increasing hospitalization. The reintervention rate and spinal cord ischemia rate are higher in patients with bilateral IAA compared with those with no IAA.

A Meta-analysis of Comparative Outcome and Cost-Effectiveness of Internal Iliac Artery Embolization with Vascular Plug Versus Coil.

PURPOSE: To evaluate the comparative outcome and cost of vascular plugs versus coils for internal iliac artery embolization prior to endovascular aortic aneurysm repair. METHOD: A search was performed for internal iliac artery embolization studies in adult patients from January 2005 to July 2018. Inclusion criteria included embolization of unilateral or bilateral IIAs with either coils or plug(s) prior to endovascular aortic repair. Meta-analysis was performed using a fixed effects model with the inverse variance-weighted average method to determine pooled differences in surgical time, fluoroscopy time, radiation exposure, number of devices used, cost of devices, and post-embolization buttock claudication. Heterogeneity was assessed using the Chi-square statistic. Pooled outcomes were compared, and quality assessments were evaluated using the Newcastle-Ottawa scale. RESULT: Six studies met inclusion criteria. One hundred and eighty-one patients were included in the study, of which 87 were in the plug group and 94 in the coil group. Vascular plug use led to 35.32 min shorter surgery time (p < 0.001), 15.64 min less fluoroscopy time (p < 0.001), 157,599 mGy/cm2 less radiation (p < 0.001), and 5.88 fewer occlusive devices (p < 0.001) than the use of coils alone. The estimated total cost of occlusion devices was $575.45 USD lower in the plug cohort (p < 0.001). The development of buttock claudication 12 months after EVAR was 11% less likely in the plug cohort but was not statistically significant (p = 0.71). CONCLUSION: The vascular plug appears to be superior to coils in embolization of the internal iliac artery due to shorter surgical time, fluoroscopy time, radiation exposure, and total cost of occlusive devices.

Volume Change after Endovascular Treatment of Common Iliac Arteries ≥ 17 mm Diameter: Assessment of Type 1b Endoleak Risk Factors.

OBJECTIVE: The aim of this study was to assess the post-operative volumetric evolution of common iliac arteries (CIA) ≥ 17 mm diameter with respect to the type of endovascular technique performed and to assess type 1b endoleak risk factors. METHODS: All consecutive patients presenting with aneurysmal disease with CIA ≥17 mm treated endovascularly from 2008 to 2016 were included. Patients were divided into two groups dependent upon the type of endovascular technique performed: bell bottom technique (BBT group), vs. other techniques (non-BBT group). Volumetric evolution of the CIA was assessed for each patient by computed tomography angiographic reconstructions performed pre-operatively, at six months, one year, and two years. Multivariable analysis was performed to identify risk factors for type 1b endoleak. RESULTS: From 2008 to 2016, 74 patients with 110 CIA ≥17 mm were treated (BBT group: n = 58; non-BBT group: n = 52). Mean follow up was 48.1 months (median 39.0, IQR 38.1). Mean volumetric evolution significantly differed in the BBT group +14.2% (median 19.9%, IQR 24.6) compared with the non-BBT group: -20.9% (median -20.1%, IQR -26.0), p < .001. The five year type 1b endoleak related re-intervention rate was 16.1% and 7.7% in the BBT and non-BBT groups, respectively (p = .04), mean time to type 1b endoleak was 24.8 months and 54.3 months, respectively. The BBT appeared as a risk factor for type 1b endoleak (OR: 7.13; 95% CI: 1.58-3.04; p < .001). CONCLUSION: The BBT is associated with an increase in CIA volume post-operatively and consequently can be considered a risk factor for type 1b endoleak. It might be avoided if an iliac branched endograft is possible.

Overstenting the hypogastric artery during endovascular aneurysm repair with and without prior coil embolization: A comparative analysis from the ENGAGE Registry.

BACKGROUND: Endovascular aneurysm repair of aortoiliac or iliac aneurysms is often performed with stent graft coverage of the origin of the hypogastric artery (HA) to ensure adequate distal seal. It is considered common practice to perform adjunctive coiling of the HA to prevent a type II endoleak. Our objective was to question the necessity of pre-emptive coiling by comparing the outcomes of HA coverage with and without prior coil embolization. METHODS: Data from the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE), which prospectively enrolled 1263 endovascular aneurysm repair patients between March 2009 and April 2011 from multiple centers worldwide, were used for this study. We identified patients in whom the Endurant stent graft (Medtronic Vascular, Santa Rosa, Calif) covered one or both HAs and grouped them into cases in which prior HA embolization-coils or plugs-was performed (CE) and cases in which HA embolization was not performed (NE). The occurrence of covered HA-related endoleak and secondary interventions were compared between groups. RESULTS: In 197 patients, 225 HAs were covered. Ninety-one HAs were covered after coil embolization (CE group), and 134 HAs were covered without prior coil embolization (NE group). Both groups were similar at baseline and had comparable length of follow-up to last image (665.2 ± 321.7 days for CE patients; 641.6 ± 327.6 days for NE patients; P = .464). Importantly, both groups showed equivalent iliac morphology concerning common iliac artery proximal, mid, and distal dimensions and tortuosity, making them suitable for comparative analysis. During follow-up, HA-related endoleaks were sparse and occurred equally often in both groups (CE 5.5% vs NE 3.0%; P = .346). Secondary intervention to resolve an HA-related endoleak was performed twice in the CE group and three times in the NE group. Late non-HA-related endoleaks occurred more often in the CE group compared with the NE group, (25.0% vs 15.0%; P = .080). Secondary interventions for other reasons than HA-related endoleaks occurred in 7.5% of NE cases and 15.4% of CE cases (P = .057), mostly for occlusions in the ipsilateral iliac limb. During follow-up, 19 NE patients and 9 CE patients died, which is not significantly different (P = .225), and no deaths were related directly or indirectly to HA coverage. Also, no reports of gluteal necrosis and bowel ischemia were made. CONCLUSIONS: This study shows that HA coverage with the Endurant endograft without prior coil embolization does not increase the incidence of endoleak or related secondary interventions. These findings together with the already available evidence suggest that omission of coil embolization may be a more resource-effective strategy whenever HA coverage is required.

Zenith Bifurcated Iliac Side Branch Device: Mid-term Results and Assessment of Risk Factors for Intraoperative Thrombosis.

BACKGROUND: The aim of this study is to evaluate the short- and mid-term results of the Zenith bifurcated iliac side branch device (ZBIS) in the treatment of common iliac artery (CIA) aneurysms, and to assess risk factors for intraoperative internal iliac artery (IIA) thrombosis. METHODS: All patients who underwent endovascular treatment of either an isolated CIA aneurysm or an aortoiliac aneurysm using the ZBIS device in the departments of vascular surgery of Strasbourg (France) and Lausanne (Switzerland) between January 2010 and December 2014 were retrospectively collected. RESULTS: Thirty-one implantations were performed: 30 patients underwent 31 endovascular CIA aneurysm treatments with the ZBIS device. Mean operative time was 188 min. Technical success was obtained in 26 implantations (84%). In 5 implantations (16%), the final angiogram revealed an IIA thrombosis. Thirty-day mortality was 3.2%. Thirty-day morbidity was 13.3%. Mean follow-up was 15 months. Overall survival was 96% at 1 year and 89% at 2 years. In intention-to-treat analysis, primary patency of the internal iliac side branch was 84% at 1 year and 76% at 2 years (5 peroperative IIA occlusions and 1 late occlusion). Freedom from reintervention was 89% at 1 and 2 years. One case of type III endoleak and 2 cases of type II endoleaks were identified. Only type III endoleak required an additional intervention with a covered stent. Aneurysm diameter decreased in 15 implantations (48%) and remained stable in 16 implantations (52%). Clinical, radiological, and peroperative parameters were analyzed to identify risk factor for intraoperative thrombosis of the internal iliac side branch. Notion of intraoperative difficulties (any additional procedure that was not initially planned and increasing the operating time) appeared as a risk factor in multivariate analysis (P < 0.01, standard deviation 1.27, odds ratio 30.6). CONCLUSIONS: The main findings of our study is that the procedure can be difficult to perform in particular conditions and can lead to peroperative failure in these cases, highlighting the need for adequate patients screening. When technical success is obtained, outcomes can be considered as satisfactory.

Is Age a Determinant Factor in EVAR as a Predictor of Outcomes or in the Selection Procedure? Our Experience.

INTRODUCTION: Endovascular aneurysm repair (EVAR) is the therapy of choice in high risk patients with abdominal aortic aneurysm. The good results described are leading to the broadening of clinical indications to younger patients. However, reintervention rates seem higher and even with successful treatment sometimes there is growth of the aneurysm sac and rupture, meaning a failure of the therapeutic goal. This study proposes to analyse the impact of age in patients' selection and post-EVAR results. METHODS: The clinical records of consecutive patients undergoing endovascular aneurysm repair, between 2001 and 2013, were retrospectively reviewed. Patients were divided according to age groups (<70, 70-80 and >80 years). Gender, body mass index, aneurysm anatomic features, neck characteristics, iliac morphology, surgical indication, endograft type, anesthesic risk classification, length of stay, reinterventions and mortality were analysed and compared. RESULTS: The study included 171 patients, 161 (94.1%) men, and mean age 74.1±8.9 years. The age group under 70 had 32% of the patients. Only three characteristics were found different among age groups: 1) body mass index was higher in younger patients, with a considerable trend toward significance (P=0.06); 2) surgical indication, in the younger group, surgeon's and the patient's option were more proeminent (P<0.05); 3) erectile dysfunction was higher in elderly group (P<0.05). No other clinical and anatomical characteristics or final outcomes were found statisticaly different among age groups. CONCLUSION: The absence of statistically differences in mortality and reinterventions among age groups suggests that age by itself is not a relevant factor in endovascular aneurysm repair. Indeed, the three characteristics different in younger (obesity, sexual function and patient's choice) favor endovascular aneurysm repair.

Is age a determinant factor in evar as a predictor of outcomes or in the selection procedure? our experience

Abstract Introduction: Endovascular aneurysm repair (EVAR) is the therapy of choice in high risk patients with abdominal aortic aneurysm. The good results described are leading to the broadening of clinical indications to younger patients. However, reintervention rates seem higher and even with successful treatment sometimes there is growth of the aneurysm sac and rupture, meaning a failure of the therapeutic goal. This study proposes to analyse the impact of age in patients' selection and post-EVAR results. Methods: The clinical records of consecutive patients undergoing endovascular aneurysm repair, between 2001 and 2013, were retrospectively reviewed. Patients were divided according to age groups (<70, 70-80 and >80 years). Gender, body mass index, aneurysm anatomic features, neck characteristics, iliac morphology, surgical indication, endograft type, anesthesic risk classification, length of stay, reinterventions and mortality were analysed and compared. Results: The study included 171 patients, 161 (94.1%) men, and mean age 74.1±8.9 years. The age group under 70 had 32% of the patients. Only three characteristics were found different among age groups: 1) body mass index was higher in younger patients, with a considerable trend toward significance (P=0.06); 2) surgical indication, in the younger group, surgeon's and the patient's option were more proeminent (P<0.05); 3) erectile dysfunction was higher in elderly group (P<0.05). No other clinical and anatomical characteristics or final outcomes were found statisticaly different among age groups. Conclusion: The absence of statistically differences in mortality and reinterventions among age groups suggests that age by itself is not a relevant factor in endovascular aneurysm repair. Indeed, the three characteristics different in younger (obesity, sexual function and patient's choice) favor endovascular aneurysm repair.

Editor's Choice - ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus): A French Randomized Controlled Trial of Endovascular Versus Open Surgical Repair of Ruptured Aorto-iliac Aneurysms.

OBJECTIVES/BACKGROUND: ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus) is a prospective multicentre randomized controlled trial including consecutive patients with ruptured aorto-iliac aneurysms (rAIA) eligible for treatment by either endovascular (EVAR) or open surgical repair (OSR). Inclusion criteria were hemodynamic stability and computed tomography scan demonstrating aorto-iliac rupture. METHODS: Randomization was done by week, synchronously in all centers. The primary end point was 30 day mortality. Secondary end points were post-operative morbidity, length of stay in the intensive care unit (ICU), amount of blood transfused (units) and 6 month mortality. RESULTS: From January 2008 to January 2013, 107 patients (97 men, 10 women; median age 74.4 years) were enrolled in 14 centers: 56 (52.3%) in the EVAR group and 51 (47.7%) in the OSR group. The groups were similar in terms of age, sex, consciousness, systolic blood pressure, Hardman index, IGSII score, type of rupture, use of endoclamping balloon, and levels of troponin, creatinine, and hemoglobin. Delay to treatment was higher in the EVAR group (2.9 vs. 1.3 hours; p < .005). Mortality at 30 days and 1 year were not different between the groups (18% in the EVAR group vs. 24% in the OSR group at 30 days, and 30% vs. 35%, respectively, at 1 year). Total respiratory support time was lower in the EVAR group than in the OSR group (59.3 hours vs. 180.3 hours; p = .007), as were pulmonary complications (15.4% vs. 41.5%, respectively; p = .050), total blood transfusion (6.8 vs. 10.9, respectively; p = .020), and duration of ICU stay (7 days vs. 11.9 days, respectively; p = .010). CONCLUSION: In this study, EVAR was found to be equal to OSR in terms of 30 day and 1 year mortality. However, EVAR was associated with less severe complications and less consumption of hospital resources than OSR.

Abdominal aortic aneurysms-gender aspects on prevalence, treatment, and concurrent aneurysms.

Fewer women than men suffer from abdominal aortic aneurysms (AAAs). The women who are diagnosed with this fatal disease are more generally diseased, have a higher risk of concurrent thoracic aortic aneurysms, have a lower chance of endovascular aortic repair treatment, have a higher complication rate, and presumably, have a poorer survival rate than men with AAAs and other women in the population. This is an overview on prevalence, treatment, outcome, and multilevel aneurysm disease in women with AAAs compared with men.

Occlusion of the internal iliac artery prior EVAR: comparison of coils and plugs.

PURPOSE: We compared occlusion of the internal iliac artery (IIA) using coils or the Amplatzer vascular plug (AVP) II prior to endovascular aortic aneurysm repair. MATERIALS AND METHODS: Occlusion of the IIA was performed in 32 patients (aged 74 ± 8 years) using coils (N = 17) or the AVP II (N = 15). We retrospectively compared procedural data, initial success, and clinical outcome in a 12-month follow-up. RESULTS: Occlusion was successful in all patients without detection of an endoleak after 12 months. Procedure time and fluoroscopy time for coils versus plugs were 77 ± 35 versus 43 ± 13 minutes and 36 ± 19 versus 18 ± 8 minutes, respectively (P < .003). Incidence of initial buttock claudication (BC) for coils versus plugs was 47% versus 27% and was significantly more severe after coil occlusion (P = .03). After a 12-month follow-up, 2 patients of each group reported of mild BC. CONCLUSION: Occlusion of the IIA is safe and effective using coils or plugs. Initial BC is significantly more severe when coils are used, but after a 12-month follow-up, there is no significant difference. Using a plug is associated with a significant reduction of procedure time and radiation exposure.

Endovascular aneurysm repair with preservation of the internal iliac artery using the iliac branch graft device.

OBJECTIVES: Aortoiliac aneurysms comprise up to 43% of the specialist endovascular caseload. In such cases endovascular aneurysm repair (EVAR) requires distal extension of the aortoiliac endograft beyond the ostium of the internal iliac artery (IIA) and into the external iliac artery, conventionally necessitating the embolisation of one or both IIA. This has been associated with a wide range of complications, and the use of an Iliac Branch-graft Device (IBD) offers an appealing endovascular solution. DESIGN: Medline, trial registries, conference proceedings and article reference lists were searched to identify case series reporting IBD use. Data were extracted for review. RESULTS: Nine series have reported the use of IBD in a total of 196 patients. Technical success was 85-100%. Median operating times were 101-290min and median contrast dose was 58-208g, with no aneurysm-related mortality. Claudication developed in 12/24 patients after IBD occlusion. One type I endoleak and two type III endoleaks occurred and were managed endovascularly. Re-occlusion occurred in 24/196 patients. CONCLUSION: IBD was performed with high technical success rates and encouraging mid-term patency. Formalised risk stratification and morphological data are required to identify the group of patients who will benefit most. Cost-effectiveness appraisals are needed for this technique.

Implementation of an aortic screening program in clinical practice: implications for the Screen For Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act.

OBJECTIVE: Screening for abdominal aortic aneurysms (AAA) significantly reduces aneurysm-related death. In January 2007, the Federal government enacted Medicare coverage guideline to screen persons at risk for the presence of an AAA, the Screen for Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act. The purpose of this study is to evaluate the efficacy and costs of a large scale screening effort for identifying AAAs in patients in clinical practice. METHODS: A regional veterans affairs mandate for screening for AAA was implemented in February 2007. Data were extracted through the Northern California Veterans Affairs (VA) Service Network to identify veteran males 65-75 years of age who ever smoked at least 100 cigarettes during their lifetime. An AAA was defined as an aortic diameter 3.0 cm or greater. A Decision Support Systems software (LumiData, Minneapolis, Minn) package tracked true costs of conducting a large AAA screening protocol in the Northern California VA Health Care System. RESULTS: A total of 2918 patients (average age, 71 +/- 6 years) were screened for AAA over a 1-year period from February 2007 to February 2008. An AAA was diagnosed in 5.1% (148/2918) of patients. Two hundred ninety patients out of the 2918 (9.9%) were inappropriately screened. The aneurysm distribution was as follows: 83% (123/148) of the aneurysms were 3.0-4.4 cm, 13% (19/148) were 4.5-5.5 cm, and 4.1% (6/148) were greater than 5.5 cm. Incidental findings of isolated iliac artery aneurysms were found in 0.1% (3/2918) of patients. The cost of AAA screening per patient is $53. CONCLUSION: The results of a large AAA screening effort in clinical practice reflect the results reported in the major clinical trials at a reasonable cost. The identification of large iliac artery aneurysms in the screening has not been previously reported.

Transluminal hypogastric artery occlusion with an Amplatzer vascular plug during endovascular aortic aneurysm repair.

OBJECTIVE: To evaluate our initial experience with hypogastric artery occlusion using a nitinol vascular plug during endovascular aortic aneurysm repair (EVAR). METHODS: We reviewed the records and images of 23 consecutive patients who underwent transluminal vessel occlusion of the hypogastric artery with a nitinol plug, as well as a cohort of 19 patients who underwent hypogastric artery embolization with coils in conjunction with EVAR. RESULTS: There were no demographic differences between the two groups of patients. Hypogastric artery occlusion was successful in all cases when a nitinol vascular plug was used. When coils were used, there was one unsuccessful embolization which required a second procedure. The number of embolic devices used in the coil group was 7.53 (range, three to 13) compared with 1.35 (range, one to six) in the plug group (P < .05). Only one plug was used in 19 of 23 cases. The average cost to embolize per hypogastric artery was $1,496 compared with $470 when a nitinol plug was used. There were two instances of coil migration. No other intraoperative complications occurred. At one month follow up, seven patients (35%) in the coil group complained of buttock claudication compared with two patients (9%) in the nitinol plug group (P = .027). CONCLUSION: Our experience demonstrates the safety and effectiveness of the nitinol vascular plug for hypogastric artery occlusion during EVAR. When compared with coils for hypogastric embolization during EVAR, nitinol vascular plugs are less expensive, produce less technical complications, and are associated with a significantly lower incidence of gluteal claudication.

Embolization of the internal iliac artery: cost-effectiveness of two different techniques.

The purpose of this study was to compare the cost-effectiveness of coils versus the Amplatzer Vascular Plug (AVP) for occlusion of the internal iliac artery (IAA). Between 2002 and January 2006, 13 patients (mean age 73 +/- 13 years) were referred for stent-grafting of abdominal aortic aneurysm (n = 6); type I distal endoleak (n = 3), isolated iliac aneurysm (n = 3), or rupture of a common iliac aneurysm (n = 1). In all patients, extension of the stent-graft was needed because the distal neck was absent. Two different techniques were used to occlude the IIA: AVP in seven patients (group A) and coil embolization in six patients (group C). Immediate results and direct material costs were assessed retrospectively. Immediate success was achieved in all patients, and simultaneous stent-grafting was successfully performed in two of six patients in group C versus five of seven patients in group A. In all group A patients, a single AVP was sufficient to achieve occlusion of the IIA, accounting for a mean cost of 485 euros, whereas in group C patients, an average of 7 +/- 3 coils were used, accounting for a mean cost of 1,745 euros. Mean average cost savings using the AVP was 1,239 euros. When IIA occlusion is needed, the AVP allows a single-step procedure at significant cost savings.

Amplatzer Vascular Plug to occlude the internal iliac arteries in patients undergoing aortoiliac aneurysm repair.

PURPOSE: The purpose of this report is to evaluate the use of conventional coils and the Amplatzer Vascular Plug, a type of nitinol-based self-expanding device, to occlude the internal iliac artery in patients undergoing aortoiliac or common iliac aneurysm endograft repair, or both. METHODS: Between August and December 2004, in preparation for endograft repairs of aortoiliac or common iliac artery aneurysms, or both, at a community hospital system, five patients underwent the occlusion of the internal iliac artery with an Amplatzer Vascular Plug to prevent endoleak. During the preceding 12 months, the conventional coil embolization of the internal iliac artery was used for the same purpose in 10 patients. RESULTS: In five patients undergoing the Amplatzer Vascular Plug occlusion of the internal iliac artery, precise deployment at the origin of the artery was achieved. Complete and precise occlusion was confirmed angiographically, and only one device was used for each internal iliac artery. Two patients reported mild buttock claudication 2 weeks after occlusion, which resolved completely by 6 and 8 weeks, respectively. A type II endoleak from the inferior mesenteric artery developed in one patient. In the previous 10 patients, 11 internal iliac arteries were treated with conventional coils. Subsequent repeat coil embolization was required for three patients. The procedural complications in this second group included one case of coil embolization into the superficial femoral artery and one into the common iliac artery; both errant coils were retrieved successfully by endovascular techniques. An average of 7 +/- 3.4 (mode of 5) coils were used for each internal iliac artery. Three cases of buttock claudication occurred after the unilateral internal iliac artery occlusion in this group and did not resolve. No evidence of ischemic bowel, buttock necrosis, or sexual dysfunction was observed in either group. The estimated average cost to occlude one internal iliac artery was 375 dollars for Amplatzer Vascular Plugs and 3,500 dollars for conventional coils. CONCLUSIONS: The Amplatzer Vascular Plug allows for a cost-effective method to occlude the internal iliac artery in patients undergoing endograft repairs of aortoiliac aneurysms. The use of a single device with a precise placement at the origin of the artery minimizes cost and avoids ischemic complications.

Screening cost for abdominal aortic aneurysms: Japan-based estimates.

PURPOSE: The aim of this study was to evaluate the screening procedures in Japan economically focusing on the screening costs and the hospital costs for abdominal aortic aneurysm (AAA) surgery. METHODS: A total of 10,057 residents, 60 years of age or older, including 4 247 men and 5 810 women, participated in the screening test for AAA using ultrasound. RESULTS: Aneurysms were detected in 34 participants, including 32 men and 2 women. The detection rate of AAA was 0.8% in men, 0.03% in women, and 0.3% in total. It cost 8 US dollars to screen each participant, and the cost to detect each aneurysm was thus estimated at 1,250 dollars in men, 23,240 dollars in women, and 2,366 dollars in total. The difference in the mean hospital cost between ruptured and nonruptured AAA was 21,833 dollars in our recent cases. Obesity, male sex, and smoking habits were all significant risk factors for AAA. CONCLUSION: Screening for AAA using ultrasound is useful not only for the early detection of AAA but also for a reduction in the overall medical cost.