Incidence and Treatment of Limb Occlusion of the Anaconda Endograft After Endovascular Aneurysm Repair.

PURPOSE: To evaluate the incidence and treatment of limb occlusions of the second- and third-generation Anaconda endografts. METHODS: A single-center retrospective study was conducted involving 317 consecutive patients (mean age 76 years; 289 men) who underwent endovascular aneurysm repair for elective asymptomatic, symptomatic intact, and ruptured infrarenal abdominal aortic aneurysm with 2 versions of the Anaconda device. From September 2003 to July 2011, the second-generation device was used in 189 patients (mean age 77 years; 169 men) and from July 2011 to September 2015, the third-generation device was implanted in 128 patients (mean age 75 years; 120 men). The rates of limb occlusion were compared between groups and according to compliance with the instructions for use (IFU); predictors were sought in multivariate analysis. The results of the latter are given as the hazard ratio (HR) and 95% confidence interval (CI). RESULTS: Kaplan-Meier freedom of occlusion estimates for second- and third-generation devices, respectively, was 96.6% and 95.0% at 1 year, 89.9% and 95.0% at 2 years, and 86.5% and 88.6% at 5 years. There was no significant difference in overall occlusion rate between the second-generation devices (p=0.332) or with regard to use within the IFU (p=0.827); however, there was a clinically relevant decrease in the occlusion rate for elective patients treated with the third-generation device (6.4% vs 13.1%, p=0.077). There was an increase in the occlusion rate when the iliac limb diameter was ≤13 mm. In multivariate analysis, the only independent predictor of limb occlusion was a small distal prosthesis diameter (HR 0.732, 95% CI 0.63 to 0.86, p<0.001). Symptomatic nonruptured and ruptured abdominal aortic aneurysm (AAA) interventions had an almost 2-fold increased risk of occlusion (HR 1.95, 95% CI 0.93 to 4.11, p=0.078), though this did not reach statistical significance. CONCLUSION: The Anaconda design has proven effectiveness in AAA exclusion in daily practice inside the IFU. However, efforts could be made to further reduce the limb occlusion rate.

Results of the Anaconda endovascular graft in abdominal aortic aneurysm with a severe angulated infrarenal neck.

OBJECTIVE: Proximal neck anatomy of an abdominal aortic aneurysm (AAA), especially a severe angulated neck of more than 60 degrees, predicts adverse outcome in endovascular aneurysm repair. In the present study, we evaluate the feasibility of the use of the Anaconda endovascular graft (Vascutec, Terumo, Inchinnan, Scotland) for treating infrarenal AAA with a severe angulated neck (>60 degrees) and report the midterm outcomes. METHODS: In total, nine Dutch hospitals participated in this prospective cohort study. From December 2005 to January 2011, a total of 36 AAA patients, 30 men and six women, were included. Mean and median follow-up were both 40 months. RESULTS: Mean infrarenal neck angulation was 82 degrees. Successful deployment was reached in 34 of 36 patients. Primary technical success was achieved in 30 of 36 patients (83%). There was no aneurysm-related death. Four-year primary clinical success was 69%. In the first year, eight clinical failures were reported including four leg occlusions which could be solved using standard procedures. After the first year, three patients with additional failures occurred; two of them were leg occlusions. Four patients needed conversion to open AAA exclusion. In six of 36 patients, one or more reinterventions were necessary. Three of them were performed for occlusion of one Anaconda leg and two were for occlusion of the body. CONCLUSIONS: The use of the Anaconda endovascular graft in AAA with a severe angulated infrarenal neck is feasible but has its side effects. Most clinical failures occur in the first year. Thereafter, few problems occur, and midterm results are acceptable. Summarizing the present experiences, we conclude that open AAA repair is still a preferable option in patients with challenging aortic neck anatomy and fit for open surgery.

[An unexpected pathology report of a sentinel lymph node]. / Onverwachte bevinding in de schildwachtklier.

A 60-year-old woman was treated for breast carcinoma. She underwent a total mastectomy with sentinel node biopsy of her right breast. Pathologic examination of the sentinel lymph node showed an unusual large nodal naevus.

[Spontaneous, atraumatic rupture of the spleen in a young man]. / Een atraumatische spontane miltruptuur bij een jonge man.

BACKGROUND: A spontaneous, atraumatic splenic rupture is a splenic rupture without a history of trauma. Rupture of this type may occur in a healthy patient but may also be seen in the context of an underlying neoplastic, haematological, infectious or local inflammatory condition. CASE DESCRIPTION: A 30-year-old man presented to the emergency department with acute pain in the left shoulder, thorax and upper abdomen, accompanied by signs of haemodynamic instability. No history of trauma was reported. Because the clinical symptoms could fit various abdominal and thoracic conditions, he was sent for a CT scan. This revealed a splenic rupture with haemoperitoneum. Emergency laparotomy and splenectomy were performed. Anamnestic, histopathological and other supplementary investigations revealed no indications of underlying pathology so that a diagnosis of "atraumatic idiopathic splenic rupture" was made. CONCLUSION: It is clinically difficult to diagnose a spontaneous, atraumatic rupture of the spleen due to the overlap in presentation with other, more common abdominal and thoracic conditions. A CT scan is essential to detect such a rupture promptly in order to provide appropriate surgical intervention.

Consistency in endovascular aneurysm repair suitability assessment requires group decision audit.

INTRODUCTION: Proper selection of patient and stent-graft combinations in endovascular aneurysm repair (EVAR) depends on knowledge and experience with the different types of stents that have to be adapted to the patient's unique abdominal aortoiliac anatomy. The aim of this study was to analyze the consistency and variance in EVAR suitability assessment between clinicians. METHODS: Worksheets that contained anatomic data derived from computed tomography scans and angiography were compiled for 202 patients. Five clinicians, all experienced in EVAR surgery, assessed the anatomic data on the worksheets for suitability for three types of stent-grafts. The obtained 3030 assessments represented a quantification of the likelihood of success the clinician expected for effective and durable sealing and fixation of the stent-graft in EVAR. The Delphi method was used to determine consensus in the thinking process among clinicians, and kappa analysis was used to determine the proportion of variances in the assessment result between clinicians. RESULTS: With the Delphi method, Cronbach alpha values of 0.87, 0.87, and 0.90 were reached for the three types of stent-grafts in the second assessment round. The individual clinician-group correlation in round two was between 0.69 and 0.86 for clinicians 1, 2, 3, and 4. Between clinician 5 and the others, correlation varied between 0.43 and 0.64. The kappa values ranged between 0.32 and 0.51 among clinicians 1, 2, and 3. Between clinician 5 and the others, kappa values between 0.08 and 0.29 were reached. CONCLUSION: EVAR suitability estimation in a cohort of patients is highly consistent in a group of experienced clinicians. The EVAR suitability estimation at the individual patient level varies substantially between clinicians, however. Aggregating expert opinions in abdominal aortic aneurysm anatomic suitability assessment for EVAR had the opportunity to replace individual clinician decision diversification in a more solid and consistent group decision process.