RESUMEN
BACKGROUND: The endovascular aneurysm repair (EVAR) is a successful treatment for aorto-iliac aneurysms. The success of EVAR is enhanced by the use of devices that maintain the patency of targeted arteries namely the iliac branch device (IBD) With this study we aimed to evaluate the association between the use of Jotec E-ventus during EVAR with IBD and prognosis in patients with aorto-iliac aneurysms. METHODS: This is a retrospective, multicentric study enrolling patients referred to our Vascular Surgery Units from January 2015 to January 2020. All patients underwent EVAR with IBD using Jotec E-ventus as bridging stent. Primary endpoint was the development of types I and III endoleaks. Secondary endpoint was the onset of device occlusion with loss of vascular patency. RESULTS: We studied 32 patients (mean age 71.7±4.5y). Of these, 25 patients were treated with standard EVAR procedure whereas 7 were treated with isolated IBD due to extension of disease involving iliac bifurcation. Median follow-up lasted 15[IQR11-27] months. During follow-up, incidence rates for endoleaks and occlusion were 3.98(95%CI 0.48-14.41) and 1.99(95%CI 0.05-11.12) per 100 pts/year. CONCLUSIONS: Jotec E-ventus during EVAR is associated with a low rate of severe complications in a small cohort of patients with aorto-iliac aneurysms.
Asunto(s)
Aneurisma de la Aorta/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Aneurisma Ilíaco/cirugía , Stents , Anciano , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Estudios Transversales , Endofuga/etiología , Endofuga/fisiopatología , Procedimientos Endovasculares/efectos adversos , Femenino , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/fisiopatología , Humanos , Aneurisma Ilíaco/diagnóstico por imagen , Aneurisma Ilíaco/fisiopatología , Italia , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
As the use of endovascular approaches to treat aneurysm repair continues to increase, more and more patients have been identified with endoleaks. Five types of endoleaks have been defined. Endotension, or type V endoleak, remains controversial owing to its variable definition across studies and the range of proposed treatments. Thus, we performed a review of the reported studies to summarize the diagnosis and treatment of this rare complication after endovascular aneurysm repair to determine what we do and do not know about this rare form of endoleak. The presence of an endoleak places patients at an increased risk of aneurysm sac enlargement and potential rupture. Although additional research is essential and yet difficult to perform, we sought to provide a guide for the management of this perplexing endoleak known as endotension.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/fisiopatología , Endofuga/diagnóstico por imagen , Endofuga/fisiopatología , Endofuga/terapia , Humanos , Medición de Riesgo , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Despite the great evolution of endograft devices for thoracic endovascular aortic repair (TEVAR), threatening related complication such as graft migration and endoleaks still occur during follow up. The Drag Forces (DF), that is the displacement forces that play a role in graft migration and endoleaks caused by the blood flow against the thoracic graft, can be studied by means of Computational Fluid Dynamics (CFD). METHOD: A general review of papers found in current literature was performed. CFD studies available on the topic of thoracic aortic diseases and DF were analyzed. All anatomic, hemodynamics or graft related factors which could have an impact on DF were reported. RESULTS: Different factors deeply influence DF magnitude in the different site of the Ishimaru's zones classification: angulation, tortuosity and length of the landing zone, graft diameter, length and deployment position, blood pressure, pulse waveform, blood viscosity and patient heart rate have been related to the magnitude of DF. Moreover, also the three-dimensional orientation of DF is emerging as a fundamental issue from CFD studies. DF can be divided in sideways and upward components. The former, even of higher magnitude in zone 0, maintain always an orthogonal orientation and does not change in any type of aortic arch; the latter result strictly related to the anatomic complexity of the aortic arch with values up to four times higher in zone 3. CONCLUSION: Different DF magnitude and orientation could explain how TEVAR have higher rate of migration and endoleaks when we face with more complex aortic anatomies. All these aspects should be foreseen during the planning of TEVAR procedure. In this field, collaboration between physicians and engineers is crucial, as both parts have a primary role in understanding and describing hidden aspects involved in TEVAR procedures.
Asunto(s)
Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular/efectos adversos , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Migración de Cuerpo Extraño/etiología , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/fisiopatología , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/instrumentación , Endofuga/diagnóstico por imagen , Endofuga/fisiopatología , Procedimientos Endovasculares/instrumentación , Migración de Cuerpo Extraño/diagnóstico por imagen , Migración de Cuerpo Extraño/fisiopatología , Humanos , Hidrodinámica , Modelos Cardiovasculares , Modelación Específica para el Paciente , Flujo Sanguíneo Regional , Medición de Riesgo , Factores de Riesgo , Estrés Mecánico , Resultado del TratamientoRESUMEN
A type-2 endoleak after an endovascular aneurysm repair is the most prevalent type of endoleak, but as the clinical consequence of its diagnosis is uncertain, at present, management decisions are solely based on aneurysm sac growth. The aim of this study was to investigate the potential of various computed tomography perfusion parameters for their ability to distinguish high-risk type-2 endoleaks from low-risk type-2 endoleaks after an endovascular aneurysm repair.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Aortografía , Implantación de Prótesis Vascular/efectos adversos , Angiografía por Tomografía Computarizada , Endofuga/diagnóstico por imagen , Procedimientos Endovasculares/efectos adversos , Imagen de Perfusión , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/fisiopatología , Endofuga/etiología , Endofuga/fisiopatología , Estudios de Factibilidad , Hemodinámica , Humanos , Masculino , Valor Predictivo de las Pruebas , Flujo Sanguíneo Regional , Resultado del TratamientoRESUMEN
BACKGROUND: To explore the impact of thoracic endovascular aortic repair (TEVAR) on aortic remodeling (AR) and the relationship between AR and complications after TEVAR. METHODS: A total of 56 patients (2 type IIIA aortic dissection [AD] and 54 type IIIB AD) with complicated acute type B aortic dissection suitable for TEVAR were prospectively enrolled. There were 44 men (78%) and 12 women (22%) with an average age of 54 ± 13.8 years. Aortic enhanced computed tomography (CT) was performed pre-TEVAR and 3, 6, and 12 months postoperatively. The morphological changes in AR, namely aortic volume and false lumen thrombosis, were obtained by analyzing the CT data. The effect of TEVAR on AR was determined by the morphological changes in the aorta. The relationship between AR index, false lumen thrombosis, and complications was analyzed. RESULTS: The volume of the thoracic aortic true lumen gradually increased post-TEVAR, whereas the volume of the thoracic aortic false lumen gradually decreased. The volume of abdominal aortic total lumen and false lumen increased 6 months postoperatively. The AR index increased significantly 3 months postoperatively, which was negatively correlated with complications and mortality. The thoracic and abdominal aortic false lumen thrombosis developed gradually after TEVAR, and the degree of thoracic aortic false lumen thrombosis was negatively correlated with complications and mortality. CONCLUSIONS: TEVAR promotes AR. AR index and the degree of thoracic aortic false lumen thrombosis can serve as predictors of complications and mortality.
Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Aortografía , Implantación de Prótesis Vascular , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares , Tomografía Computarizada Multidetector , Remodelación Vascular , Adulto , Anciano , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Disección Aórtica/fisiopatología , Aorta Abdominal/diagnóstico por imagen , Aorta Abdominal/fisiopatología , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/fisiopatología , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Aneurisma de la Aorta Torácica/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Endofuga/diagnóstico por imagen , Endofuga/etiología , Endofuga/fisiopatología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE: The incidence of type II endoleaks (ELII) after endovascular aneurysm repair (EVAR) ranges from 10-44%. Aneurysm thrombus density after EVAR could predict successful aneurysm exclusion. MATERIALS AND METHODS: Twenty-seven patients with an abdominal aortic aneurysm (AAA) who had a CT scan within the first 45 days (early group) post-surgery or after 7 months (late group) were included. Thrombus density was analyzed on non-contrast enhanced CT scans. RESULTS: A total of 5/13 (38%) patients in the early group had an ELII and 9/14 (64.3%) in the late group had a persistent ELII since surgery. In the early group, thrombus density was similar in patients with or without an ELII (mean: 39.9 ± 4.8 vs. 41.9 ± 3.4, p = 0.7; median: 38.7 ± 4.8 vs. 39.7 ± 3.1, p = 0.8). In patients with an ELII, there was no difference in thrombus density at 45 days and after 7 months (mean: 39.9 ± 4.8 vs. 40.2 ± 2.1, p = 0.9; median: 38.7 ± 4.8 vs. 38 ± 2.6, p = 0.9). In patients without an ELII, thrombus density was significantly higher at 45 days than after 7 months (mean: 41.9 ± 3.44 vs. 25.7 ± 2.0, p = 0.005; median: 39.7 ± 3.11 vs. 24.4 ± 1.5, p = 0.004). In patients with an ELII, thrombus density was significantly higher after 7 months than in patients without an ELII (mean: 40.2 ± 2.1 vs. 25.7 ± 2.0. p = 0.001; median: 38 ± 2.6 vs. 24.4 ± 1.5, p = 0.003). CONCLUSION: Low thrombus density after EVAR on late unenhanced CT scans predicts aneurysm exclusion.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Aortografía , Angiografía por Tomografía Computarizada , Endofuga/diagnóstico por imagen , Procedimientos Endovasculares , Trombosis/diagnóstico por imagen , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/fisiopatología , Endofuga/etiología , Endofuga/fisiopatología , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Trombosis/fisiopatología , Factores de Tiempo , Resultado del TratamientoRESUMEN
Endovascular aneurysm repair (EVAR) is now the predominant method for treatment of infrarenal abdominal aortic aneurysms. Although EVAR has numerous advantages over standard open surgical repair, it also exposes patients to risks such as aneurysm sac enlargement, endoleaks, and graft migration, which make surveillance or follow-up mandatory. Fenestrated (FEVAR) and branched (BEVAR) endografts have extended the application of EVAR to juxtarenal, pararenal/paravisceral, and thoracoabdominal aneurysms, with some complex aneurysms requiring combined approaches (F-BEVAR). Duplex ultrasound has been recommended as an alternative to frequent computed tomography imaging for EVAR follow-up when it can provide the clinically necessary information. The major components of a post-EVAR duplex examination include measurement of aortic aneurysm sac size, assessment for endoleak, and evaluation of the endograft for patency and integrity. The duplex protocol for EVAR follow-up can be extended for follow-up after FEVAR, BEVAR, and F-BEVAR, with additional attention to the device components associated with fenestrations and branches. At the University of Washington, the physician-modified endovascular graft approach has been used for FEVAR. During these procedures, covered stents are placed in the renal arteries through fenestrations and the superior mesenteric artery is perfused through a fenestration, but typically remains unstented. Duplex scanning of the renal and mesenteric arteries has been performed preoperatively and at 30 days, 6 months, 1 year, and annually. In a review of patients having covered stents placed in non-stenotic renal arteries during FEVAR, both peak systolic velocity and the renal to aortic velocity ratio remained below the standard significant stenosis threshold in most patients. The duplex velocity criteria for stenosis in native renal arteries appeared to overestimate the severity of stenosis in renal artery covered stents. The unstented superior mesenteric artery remained widely patent in the presence of fenestrations or crossing struts and was not associated with endoleaks. Duplex ultrasound protocols for follow-up after FEVAR, BEVAR, and F-BEVAR can be based on those that have been established for standard EVAR, along with assessment of fenestrations and branches, as well as patency of the renal and mesenteric arteries.
Asunto(s)
Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Endofuga/diagnóstico por imagen , Procedimientos Endovasculares , Oclusión de Injerto Vascular/diagnóstico por imagen , Ultrasonografía Doppler Dúplex , Aorta Abdominal/diagnóstico por imagen , Aorta Abdominal/fisiopatología , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Endofuga/fisiopatología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Oclusión de Injerto Vascular/fisiopatología , Humanos , Valor Predictivo de las Pruebas , Diseño de Prótesis , Factores de Riesgo , Stents , Resultado del Tratamiento , Grado de Desobstrucción VascularAsunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Circulación Colateral , Embolización Terapéutica/efectos adversos , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Aneurisma Ilíaco/terapia , Anciano , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/fisiopatología , Endofuga/diagnóstico por imagen , Endofuga/fisiopatología , Endofuga/terapia , Humanos , Aneurisma Ilíaco/diagnóstico por imagen , Aneurisma Ilíaco/fisiopatología , Masculino , Flujo Sanguíneo Regional , Resultado del TratamientoRESUMEN
BACKGROUND: The objective of this study was to evaluate the feasibility and midterm outcomes of iliac branch devices (IBDs) to preserve the internal iliac artery perfusion in emergent endovascular repair of ruptured aorto-iliac aneurysms. METHODS: Between December 2012 and July 2017, a total of 8 IBDs were implanted in 6 patients (the median age 65 years; all men) in a single tertiary referral center. The indication for IBD implantation was a ruptured abdominal aortic aneurysm with a concomitant common iliac artery aneurysm (n = 4) or isolated CIA aneurysms (n = 2). The main outcome measures were technical and clinical success. The secondary outcomes were primary and primary assisted patency, the occurrence of type I/III endoleaks, and reinterventions. RESULTS: All patients were hemodynamically stable during the procedures, which were performed under local anesthesia. Technical success was achieved in all cases (the median total procedure time of 188 min and the median IBD procedure time of 28 min). The median follow-up was 34 months (interquartile range 19-78). There were no deaths during the follow-up and no major complications unrelated to the IBD. Two (25%) secondary interventions were performed for IBD occlusion in patients with bilateral IBDs. The other reintervention was a type II endoleak embolization in 1 of these 2 patients. The freedom from reintervention estimate was 75% through 2 years. The overall primary assisted patency was 100% through 3 years. CONCLUSIONS: The use of IBDs in the acute setting is feasible to exclude ruptured aortoiliac aneurysms while maintaining pelvic circulation. The secondary intervention rate is considerable; however, the midterm assisted primary patency rates are promising. Further studies are needed to guide patient selection and to evaluate longer term outcomes.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Aneurisma Ilíaco/cirugía , Stents , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/fisiopatología , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Endofuga/etiología , Endofuga/fisiopatología , Endofuga/terapia , Procedimientos Endovasculares/efectos adversos , Estudios de Factibilidad , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/fisiopatología , Oclusión de Injerto Vascular/terapia , Hemodinámica , Humanos , Aneurisma Ilíaco/diagnóstico por imagen , Aneurisma Ilíaco/fisiopatología , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Retratamiento , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: The objective of this study was to determine the influence of hemodynamic force on the development of type III endoleak and branch thrombosis after complex endovascular thoracoabdominal aortic aneurysm repair. METHODS: Patients with thoracoabdominal aortic aneurysm, within surgical range, treated with a fenestrated or branched endovascular aneurysm repair from 2014 to 2018 and with 3-month control computed tomography angiography were selected. Demographic variables, aneurysm anatomy, and endograft conformation were analyzed retrospectively from a prospective registry. The hemodynamic force was calculated using the mass and momentum conservation equations. RESULTS: Twenty-eight patients were included; the mean follow-up period was 24.7 ± 19.3 months. There were 102 abdominal vessels successfully catheterized (19 celiac arteries, 29 superior mesenteric arteries, 27 right renal arteries, 26 left renal arteries, and 1 polar renal artery). The rate of type III endoleak was 11.5% (n = 12); six cases were associated with branches that received two stents (P < .001). A higher rate of endoleak was observed with wider stents (8.50 ± 1.0 mm vs 7.17 ± 1.3 mm; P = .001) but not with longer stents (P = .530). All cases of type III endoleak affected visceral arteries (eight celiac arteries and four superior mesenteric arteries). The freedom from type III endoleak at 24 months was 86%. The rate of thrombosis was 5.9% (n = 6). A higher rate of thrombosis was observed in smaller vessels (5.00 ± 1.3 mm vs 7.16 ± 1.8 mm; P = .001), with higher stent oversizing (36.87% ± 23.6% vs 5.52% ± 15.0%; P < .001), and with a higher angle of curvature (124.33 ± 86.1 degrees vs 57.71 ± 27.9 degrees; P < .001). All cases of thrombosis were related to renal arteries (two left renal arteries, two right renal arteries, and two polar renal arteries). The freedom from thrombosis at 24 months was 92%. The area under the curve for the angle of curvature was 0.802 (95% confidence interval, 0.661-0.943; P = .013), and the cutoff point was established at 59.5 degrees (sensitivity, 100%; specificity, 60.4%). The receiver operating characteristic curve for the stent oversize showed an area under the curve of 0.903 (95% confidence interval, 0.821-0.984; P = .001), and the cutoff point was 14.5% (sensitivity, 100%; specificity, 77.1%). A higher hemodynamic force was associated with thrombosis (23.35 × 10-3 N ± 18.7 × 10-3 N vs 12.31 × 10-3 N ± 6.8 × 10-3 N; P = .001) but not with endoleak (P = .796). The freedom from endoleak and thrombosis at 24 months was 86% and 90%, respectively. CONCLUSIONS: Longer stents should be preferred to avoid type III endoleak. A higher angle of curvature leads to a higher hemodynamic force that results in a higher rate of thrombosis. Accordingly, we recommend maintaining the angle of curvature under 59.9 degrees. Small vessels and excessive stent oversizing entail a higher risk of thrombosis; as such, we advise a maximum stent oversize of 14.5%. Renal arteries are more susceptible to thrombosis, whereas visceral arteries are more prone to endoleak.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Endofuga/epidemiología , Procedimientos Endovasculares/instrumentación , Stents/efectos adversos , Trombosis/epidemiología , Anciano , Anciano de 80 o más Años , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/fisiopatología , Aorta Torácica/cirugía , Angiografía por Tomografía Computarizada , Endofuga/diagnóstico , Endofuga/etiología , Endofuga/fisiopatología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Femenino , Estudios de Seguimiento , Hemodinámica/fisiología , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Diseño de Prótesis , Arteria Renal/diagnóstico por imagen , Arteria Renal/fisiopatología , Arteria Renal/cirugía , Estudios Retrospectivos , Factores de Riesgo , Trombosis/diagnóstico , Trombosis/etiología , Trombosis/fisiopatología , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: The Nellix EndoVascular Aneurysm Sealing (EVAS) system has offered a novel approach in the treatment of abdominal aortic aneurysm (AAA). While it is currently indicated as a primary procedure in patients with infrarenal AAA with suitable anatomy according to the indications for use, a few studies aimed to address its potential interest in failed endovascular aneurysm repair (EVAR). The aim of this systematic review was to analyze the postoperative outcomes of patients with prior EVAR who underwent EVAS. DESIGN OF THE STUDY: A literature search was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines in May 2019 and included patients with prior EVAR who underwent EVAS. The publications had to report at least one of the basic postoperative outcomes (technical success rate, all-cause complications, mortality, length of in-hospital stay, length of stay in intensive care unit, the need of re-intervention). RESULTS: Eleven studies fulfilled the inclusion criteria, for a total of 46 patients. EVAS was used to treat endoleaks in 45 cases (97.8%): 29 type Ia endoleaks (63%), 6 type IIIa endoleaks (13%), and 10 type IIIb endoleaks (21.7%). Standard EVAS procedure was performed in 21 patients (45.7%), and 25 patients (54.3%) had chimney-EVAS. The technical success was achieved in all the studies. Two patients (4.9%) died during the 30-day postoperative period, but no aneurysm-related mortality was reported. The presence of endoleaks was reported in five patients (9.8%) during the follow-up. CONCLUSION: The results suggest the safety and the efficiency of EVAS in the treatment of complications following EVAR including type Ia, type IIIa, and type IIIb endoleaks. Further studies on larger cohorts and longer follow-up periods are required to confirm the interest of EVAS in the endovascular management of failed EVAR.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Endofuga/cirugía , Procedimientos Endovasculares/instrumentación , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Endofuga/diagnóstico por imagen , Endofuga/mortalidad , Endofuga/fisiopatología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Masculino , Diseño de Prótesis , Reoperación , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Insuficiencia del TratamientoRESUMEN
BACKGROUND: Although the use of aneurysmal common iliac artery (CIA) as the landing zone during endovascular aortic aneurysm repair EVAR remains an essential procedure, this procedure may increase the risk of late complications such as ongoing CIA dilatation and type Ib endoleak (CIA-related complications). We hypothesized that incomplete sealing of the aneurysmal CIA segment during EVAR could increase the incidence of CIA-related complications. In this study, we evaluated the midterm results of EVAR with aneurysmal CIA used as the landing zone and assessed the importance of distal sealing in this procedure. METHODS: We retrospectively reviewed all cases of endovascular aneurysm repair using CIA as landing zone between 2007 and 2015 that had at least 3 years' follow-up. We defined aneurysmal CIA as maximum diameter ≥18 mm. The main outcome was the incidence of CIA-related complications. We compared midterm results between normal CIA and aneurysmal CIA. Next, we analyzed risk factors for CIA-related complications in aneurysmal CIA. RESULTS: Four complications occurred in normal CIA (mean follow-up, 66.5 ± 22.1 months); 21 occurred in aneurysmal CIA (mean follow-up, 62.2 ± 20.5 months). The 5-year portion of freedom from CIA-related complications was 97.3% in normal CIA and 69.4% in aneurysmal CIA (P < 0.001). Multivariable analysis in aneurysmal CIA showed that unsealed CIA segment length was only risk factor for CIA-related complications. Given the receiver operating characteristic curve results, we defined the unsealed CIA segment ≥10 mm as incomplete sealing. The hazard ratio for incomplete sealing associated with CIA-related complications was 3.92 (95% confidence interval 1.62-9.46, P = 0.02). CONCLUSIONS: Use of aneurysmal CIA as landing zone increases the risk of CIA-related complications. However, maximum sealing of the aneurysmal CIA segment could prevent these complications.
Asunto(s)
Aneurisma de la Aorta/cirugía , Implantación de Prótesis Vascular/efectos adversos , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Aneurisma Ilíaco/cirugía , Arteria Ilíaca/cirugía , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/instrumentación , Bases de Datos Factuales , Endofuga/diagnóstico por imagen , Endofuga/fisiopatología , Procedimientos Endovasculares/instrumentación , Femenino , Humanos , Aneurisma Ilíaco/diagnóstico por imagen , Aneurisma Ilíaco/fisiopatología , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/fisiopatología , Masculino , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: The objective of this study was to evaluate the efficacy of treating type II endoleaks (T2Ls) after aortic endovascular repair with image guidance translumbar puncture using intraoperative cone beam computed tomography with preprocedure computed tomography angiography fusion in hybrid operating rooms. METHODS: Twenty-six consecutive T2L patients in three different institutions were treated between March 2015 and September 2017 by direct translumbar puncture of the abdominal aortic aneurysm (AAA) sac after previous endovascular aortic repair. All patients were treated at a single setting in a cardiovascular hybrid operating room with a workstation featuring needle trajectory planning and guidance software. Aneurysm sac size change from the index treatment, freedom from recurrent endoleak after treatment, demographics, risk factors, and procedure factors were analyzed with univariate analysis. RESULTS: All patients (N = 26; 19 male, 7 female; age range, 59-95 years; mean body mass index, 27.44 ± 3.06 kg/m2) underwent treatment for AAA sac expansion or symptoms. Four patients had failed to respond to previous catheter-directed T2L treatment. The most common risk factors included hypertension, hypercholesterolemia, coronary artery disease, tobacco use, and diabetes. Time to initial endoleak diagnosis ranged from 2 to 1914 days (average, 404 days). Aneurysm size after initial repair was 60.3 ± 7.5 mm; sac size had increased 10.1 ± 6.5 mm at the time of treatment. Onyx (Medtronic, Irvine, Calif) or glue (n-butyl cyanoacrylate) and coil embolization was used in 20 cases, and 6 patients were treated with coiling alone. There was no difference between the patients treated with coils alone and those treated with coils or glue (P > .05) in terms of freedom from failure. Total procedure time was 75.9 ± 40.7 minutes; contrast material volume, 19.9 ± 29 mL; fluoroscopy time, 13.74 ± 12.2 minutes; and radiation dose, 121.16 ± 167.7 mGy. After embolization, the mean sac diameter decreased by 2.2 mm to 67.5 ± 9.8 mm. Average follow-up period was 214 days. In 19 patients, the sac reduced in size between 0.2 and 19.1 mm per 100 days; in 2 patients, there was continued AAA expansion (3.4-4.3 mm per 100 days); there was no change in the sac size in 5 patients after the procedure. There were no AAA ruptures during the study period. Once T2L was treated, the recurrence rate was low at 11.5%. CONCLUSIONS: This initial multicenter evaluation of the effectiveness of fusion image-guided translumbar obliteration of T2L demonstrated that the technique was effective at all three study centers and showed excellent efficacy to reduce AAA sac size. This may become a more effective and efficient method of treating T2L compared with transarterial or transcaval embolization because of its high success rate and technical ease.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Aortografía , Implantación de Prótesis Vascular/efectos adversos , Angiografía por Tomografía Computarizada , Tomografía Computarizada de Haz Cónico , Embolización Terapéutica , Endofuga/terapia , Procedimientos Endovasculares/efectos adversos , Radiografía Intervencional , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Embolización Terapéutica/efectos adversos , Embolización Terapéutica/instrumentación , Endofuga/diagnóstico por imagen , Endofuga/etiología , Endofuga/fisiopatología , Femenino , Francia , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Interpretación de Imagen Radiográfica Asistida por Computador , Radiografía Intervencional/efectos adversos , Recurrencia , Estudios Retrospectivos , Resultado del Tratamiento , Estados UnidosRESUMEN
Type II endoleak relates to aneurysm perfusion through a patent branch vessel. Reintervention for type II endoleak should be considered in the presence of significant aneurysm growth. Recurrences and subsequent reinterventions are frequent by occult type II endoleaks through feeder arterial branches. We report a case of a patient with a type II endoleak due to inferior mesenteric artery (IMA) patency associated with aneurysm sac growth after an unsuccessfully attempt of transarterial embolization. Laparoscopic ligation of the IMA with direct sac puncture embolization was performed. The postoperative and 1-year follow-up computed tomography angiography scan demonstrated no endoleak signs and aneurysm sac shrinkage. The proposed modification of this technique constitutes a novel approach to this entity. Total laparoscopic IMA ligation and direct sac puncture embolization technique may increase the success rate for the treatment of endoleaks type II by excluding the recurrences. This technique may offer a safe, feasible, and minimally invasive approach for type II endoleaks when other endovascular techniques are unsuccessful.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Embolización Terapéutica , Endofuga/terapia , Procedimientos Endovasculares/efectos adversos , Laparoscopía , Arteria Mesentérica Inferior/cirugía , Anciano , Terapia Combinada , Endofuga/diagnóstico por imagen , Endofuga/fisiopatología , Humanos , Ligadura , Masculino , Arteria Mesentérica Inferior/diagnóstico por imagen , Arteria Mesentérica Inferior/fisiopatología , Punciones , Circulación Esplácnica , Resultado del TratamientoRESUMEN
We present the case of an 86-year-old male with an aortic arch saccular aneurysm who underwent zone 1 thoracic endovascular aortic repair (TEVAR) with debranching from the right subclavian artery to the left carotid and left subclavian arteries. The patient developed a type Ia endoleak 1 month later. Postoperative contrast computed tomography (CT) showed a hematoma around the aneurysm, concerning for impending rupture. He thus underwent emergency endograft removal and replacement with a one-branched graft using selective cerebral perfusion via the left subclavian artery perfusion. The left subclavian artery was used for systemic and cerebral perfusion without need for cannulation of the cervical arteries. The patient was successfully discharged 6 months after surgery.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Remoción de Dispositivos , Endofuga/cirugía , Procedimientos Endovasculares/instrumentación , Perfusión/métodos , Arteria Subclavia/cirugía , Anciano de 80 o más Años , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/fisiopatología , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/etiología , Rotura de la Aorta/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Circulación Cerebrovascular , Endofuga/diagnóstico por imagen , Endofuga/etiología , Endofuga/fisiopatología , Procedimientos Endovasculares/efectos adversos , Hemodinámica , Humanos , Masculino , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/fisiopatología , Resultado del TratamientoRESUMEN
Traditional open total zone 0 replacement of the aortic arch is one of the most complex, challenging, and demanding operative procedures in cardiovascular surgery, associated with significant morbidity (30-40%) and mortality (8-20%). Total endovascular zone 0 replacement of the aortic arch with chimney/sandwich techniques as described by Lobato and Camacho-Lobato is a feasible, less invasive, less demanding, and time-consuming option to hybrid and/or traditional open replacement of the aortic arch, particularly in the urgent/emergent settings. We are reporting a case of a 49-year-old patient with chronic type B aortic dissection complicated with descending thoracic aortic aneurysm and an unsuccessful zone 3 thoracic endovascular aortic repair, complicated with type Ia endoleak. He presented with an enlarging and symptomatic descending thoracic aortic aneurysm. An extended proximal (to the zone 0) and distal thoracic endovascular aortic repair was performed to ensure appropriate proximal and distal landing zones (C-TAG). Left subclavian artery endorevascularization was undertaken with periscope sandwich technique (Viabahn), while brachiocephalic trunk and left carotid artery endorevascularizations were carried on with the chimney graft technique (Viabahn). The procedure was uneventful and the one-month and one-year follow-up angio-computed tomography revealed no endoleaks, patency of all branches, and exclusion of the aneurysm.
Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Endofuga/cirugía , Procedimientos Endovasculares , Disección Aórtica/diagnóstico por imagen , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Enfermedad Crónica , Endofuga/diagnóstico por imagen , Endofuga/etiología , Endofuga/fisiopatología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Humanos , Persona de Mediana Edad , Stents , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
Bilateral isolated hypogastric aneurysm (HA) is a rare type of abdominal aneurysm. Endovascular repair has become predominant compared with surgical repair because of its minimal invasiveness. However, type-II endoleak after procedure may lead to continuous enlargement of HA and rupture. Herein, we report a rare case involving a very large HA induced by type-II endoleak after endovascular repair. A 68-year-old male patient underwent endovascular repair of bilateral isolated HAs 4 years ago. Stent grafts were used to block the orifices of bilateral HAs, and main distal outflows were embolized with coils. In the absence of a 4-year follow-up, he returned to the clinic with symptoms of lower abdominal pain and frequent urination. Computer tomography angiography revealed a giant left HA with a maximum diameter of 18 cm combined with the enlargement of the left common iliac artery (CIA) induced by type-II endoleak. The right isolated HA decreased from 5.5 cm to 3 cm. Angiography was performed, and multiple arteries from the middle sacral and external iliac arteries were detected as the sources of type-II endoleak. Considering the compression effect, surgical repair of the left giant HA was performed. Thrombus was removed from the giant aneurysm, and the distal outflows of HA were sutured. As the left CIA was enlarged, a prosthetic graft was interposed through the inner side of the previous cover stent to revascularize the external iliac artery. The patient had an uneventful postoperative clinical course and was discharged from the hospital 7 days after operation. Treatments of HA induced by type-II endoleak require regular patient follow-ups to monitor specific conditions, particularly the embolization of distal outflows. Surgical repair remains the first choice for HA with compression symptoms.
Asunto(s)
Aneurisma/cirugía , Arterias/cirugía , Implantación de Prótesis Vascular , Embolización Terapéutica , Endofuga/cirugía , Procedimientos Endovasculares , Pelvis/irrigación sanguínea , Trombectomía , Anciano , Aneurisma/diagnóstico por imagen , Aneurisma/fisiopatología , Arterias/diagnóstico por imagen , Arterias/fisiopatología , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Embolización Terapéutica/efectos adversos , Endofuga/diagnóstico por imagen , Endofuga/etiología , Endofuga/fisiopatología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Humanos , Masculino , Stents , Resultado del TratamientoRESUMEN
OBJECTIVE: The natural history of endoleak type II (ET II) after endovascular aneurysm repair (EVAR) is still debatable. The aim of this study was to examine the presence of preoperative and postoperative factors associated with persistence of ET II during the initial 12-month follow-up period. METHODS: A two-center retrospective study including patients subjected to EVAR from 2006 to 2017 was undertaken. Patients with ET II at 1-month computed tomography angiography (CTA) were categorized into two groups, resolution (group 1) vs persistence (group 2) of ET II at 12-month CTA. Preoperative demographics, comorbidities, aneurysm anatomic details, and pelvic artery index were assessed. Intraoperative details were also recorded. RESULTS: Of 825 patients, 140 (17%) patients (mean age, 71.7 ± 8.5 years; 94% male) presented with ET II at 1-month CTA. Group 1 included 58 patients (41%) and group 2, 82 patients (59%). The anatomic characteristics of the inferior mesenteric artery and lumbar arteries and the pelvic artery indices were not associated with ET II persistence. All patients in group 1 had presence of intraluminal thrombus (ILT) on preoperative CTA (group 1, 100%; group 2, 67%; P = .001), and the circular pattern of ILT was more common in group 1 (group 1, 44%; group 2, 24%; P = .01). At 12-month CTA, the mean sac regression was higher in group 1 (group 1, -3 ± 4 mm; group 2, 0.55 ± 3 mm; P = .000). After multivariate analysis, persistence of ET II was directly associated only with intraoperative internal iliac occlusion (odds ratio [OR], 0.232; 95% confidence interval [CI], 0.06-0.86; P = .03) and inversely with statin therapy (OR, 2.6; 95% CI, 1.01- 6.8; P = .047) and sac regression (OR, 1.24; 95% CI, 1.11-1.39; P = .001). CONCLUSIONS: Induced occlusion of the internal iliac artery during EVAR was the only factor associated with persistence of ET II during the first year after EVAR. The presence and pattern of ILT may play a role in ET II persistence, whereas the number of patent infrarenal aortic branches and their diameter as well as the pelvic artery indices were not associated with ET II. The use of statins may have a positive effect on ET II resolution during the first postoperative year. Sac diameter is more likely to regress in patients with ET II resolution.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/fisiopatología , Arteriopatías Oclusivas/etiología , Arteriopatías Oclusivas/fisiopatología , Endofuga/diagnóstico por imagen , Endofuga/fisiopatología , Femenino , Grecia , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Arteria Ilíaca/fisiopatología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: One of the main drawbacks of endovascular aortic aneurysm repair (EVAR) compared to open aortic surgery is the possibility of developing endoleaks and secondary aneurysm rupture, requiring frequent imaging follow-up. This study aims to identify prognostic factors that could be incorporated in follow-up protocols, which might lead to better personalized, lower cost and safe EVAR follow-up. METHODS: A retrospective study was performed including all patients who underwent elective EVAR from January 2000 to December 2015. Follow-up data were gathered by reviewing medical files for radiographic imaging. Linear and logistic regressions were used to assess predictive factors for aneurysm shrinkage. RESULTS: In 361 patients, aneurysm sac shrinkage of 10 mm or more was measured in 152 (42.1%) patients. Patients with ≥10-mm aneurysm shrinkage had fewer endoleaks (4.3% vs. 24.6%, P<0.0001) and fewer re-interventions for endoleak (3.0% vs. 10.1%, P=0.007). Aneurysm sac shrinkage was correlated with the absence of endoleak development (OR 0.36, 95% CI 0.19-0.66, P=0.001). In patients who had achieved ≥10-mm shrinkage of the aneurysm sac, no further significant growth was seen, compared to 38 (15.3%) patients who did not attain size reduction (P<0.001). CONCLUSIONS: Once patients achieve ≥10-mm aneurysm sac shrinkage, they are less prone to developing subsequent aneurysm growth and have significantly lower risk of requiring surgery for endoleaks. However, a small number of patients remain at risk of requiring endoleak surgery after aneurysm shrinkage. Therefore, we would not recommend ceasing life-long imaging follow-up after significant aneurysm sac shrinkage, though it might be safe to increase the interval of follow-up.
Asunto(s)
Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular , Endofuga/diagnóstico por imagen , Procedimientos Endovasculares , Remodelación Vascular , Anciano , Anciano de 80 o más Años , Aorta Abdominal/diagnóstico por imagen , Aorta Abdominal/fisiopatología , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/fisiopatología , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/etiología , Rotura de la Aorta/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Endofuga/etiología , Endofuga/fisiopatología , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Masculino , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Endovascular aortic stent graft technology radically altered aortic aneurysm repair from a maximally invasive procedure to a minimally invasive approach. Whereas the overall principle of the repair remained the same, the surgeon ceded control of the proximal seal when suturing was eliminated. In endovascular aneurysm repair (EVAR), no longer does the surgeon control the precise placement of mechanical fasteners (sutures) between graft and tissue; rather, the graft is kept in place by creation of a seal zone that often lacks any mechanical fastening. The kinematic coupling condition is replaced by contact mechanics between the outer graft surface and the aorta. METHODS: We develop a novel computational methodology to fully model and characterize the aorta-endograft seal zone within a fully integrated aorta-EVAR model. The aorta, endograft, and intraluminal thrombus are modeled by standard finite element analysis in the limit of elastic response under pressure loading conditions. The seal zone in our simulations is fully dynamic and modeled using the cohesive zone method. Our methodology allows full separation of the aorta and endograft, simulating loss of seal and endoleak. RESULTS: Using patient-specific geometry, we show that our approach is capable of predicting the location of rupture in an index patient who presented with a ruptured juxtarenal aneurysm. Applying our novel cohesive zone method analysis to the post-EVAR geometry, we studied the stability of the endograft under several seal zone strengths correlating to very weak, standard, and very strong seal. Loss of seal is shown to correlate to the propagation of an elastic front in the aortic neck. We propose that aortic neck dilation, which develops from graft deployment and pressurization, provides an energy release mechanism that drives seal zone failure: the elasto-adhesive seal model. CONCLUSIONS: We develop the first ever fully integrated computational model of aorta-endograft seal. Our elasto-adhesive seal model provides the first biomechanical model to evaluate seal loss. We hope that our method will provide a rich tool set with which to study the vexing problems of type I endoleak and help guide the development of technologies to optimize seal.