Transrenal Endovascular Aneurysm Repair-A Novel Approach for Abdominal Aortic Aneurysms with Difficult Neck Anatomy.

BACKGROUND: The endovascular approach to treating ruptured or symptomatic abdominal aortic aneurysms (AAAs) with difficult neck anatomy still poses a major challenge. This study proposes and evaluates the outcomes of a novel technique, Transrenal Endovascular Aneurysm Repair (Tr-EVAR) which utilizes the top ring 'valley' and 'peak' configuration of the Anaconda stent graft to achieve proximal seal in AAAs with an unfavourable neck. METHODS: All patients treated with Tr-EVAR over a period of 10 years were identified retrospectively. Demographic, clinical and outcome data were collected, and survival analysis was performed. The time-to-event was analyzed using Kaplan-Meier curves for complication-free survival, reintervention-free survival, and overall survival. RESULTS: During the study period, 36 patients ruptured, symptomatic or large AAAs having unfavorable necks and not fit for open repair underwent Tr-EVAR. Two patients died in the first 30 days postprocedure (5.6%). The overall survival at 1 year, 3 years and 5 years were 86%, 72% and 54% respectively with a mean overall survival of 74.0 months (SE 7.8, 95% confidence interval 58.7-89.3) which was comparable to chimney endovascular aneurysm repair (EVAR). The complication-free survival and reintervention-free survival at 1 year, 3 years, and 5 years were 75%, 61%, 42%, 78%, 64%, and 45%, respectively. CONCLUSIONS: Tr-EVAR can be considered as an off-the-shelf solution for urgent cases not fit for open repair with unfavourable neck features for standard EVAR. Careful patient selection and planning have generated acceptable immediate, midterm and long-term results comparable to those presented by chimney EVAR in the literature.

Escalation of Antithrombotic Therapy Should Be Considered in the Presence of Intraluminal Prosthetic Graft Thrombus Following Endovascular Aneurysm Repair.

Objectives: Intraluminal prosthetic graft thrombus (IPT) following Endovascular Aneurysm Repair (EVAR) can have serious consequences. The aim of this study was to assess the prevalence of IPT and to identify the risk factors for its formation and progression. Methods: This was a retrospective study of 258 patients who had EVAR between 2015 and 2018. Demographic data, comorbidities, operative data, antithrombotic therapy, CT anatomical data, IPT characteristics (site, regression, and progression), and re-interventions were collected. Univariable analysis followed by multivariable logistic regression and Cox regression were used for data analysis. Results: The mean age of patients was 76 years (range 55-95) and 27 (10.5 %) were females. IPT was present in 26 patients (10.1%) with a median time to occurrence of six (range 1- - 24) months. Of the group that developed IPT, six (23.1 %) developed symptoms and two (7.7%) had re-interventions. Multivariable logistic regression analysis revealed peripheral arterial disease to be associated with the formation of IPT (OR 7.4, 95% CI 1.6-35.3, p = 0.02) and escalation of antithrombotic therapy was associated with regression or prevention of progression of IPT (OR 0.1, 95% CI 0.0-0.6, p = 0.01). Conclusion: PAD is associated with the formation of IPT after EVAR and warrants consideration of escalation of antithrombotic therapy to prevent further progression and complications.

Mycotic Abdominal Aortic Aneurysms - A Tertiary Centre Experience and Formulation of a Management Protocol.

BACKGROUND: Mycotic abdominal aorta aneurysm (MAAA) is a rare and life-threatening condition. Because of its rarity, there is a lack of adequately powered studies and consensus on its treatment and follow up. This study aimed to review the outcomes following surgical intervention for MAAA in a single tertiary centre and to formulate a management protocol based on available evidence and expert opinion. MATERIALS AND METHODS: Data were collected by retrospective review of case records of all patients who underwent repair of MAAA in a single tertiary referral centre from 2001 to 2018. Demographic, clinical and outcome data were analysed and compared with previously published series in the literature. A management protocol was formulated based on available literature which was then reviewed and modified as per expert opinion from multidisciplinary discussions. RESULTS: Seventeen patients underwent repair of MAAA during the study period including 4 Open repairs, 4 surgeon modified fenestrated endovascular aortic aneurysm repairs (SM FEVAR) and 9 endovascular aortic aneurysm repairs (EVAR). One-year overall survival was 94.1%, 3-year survival was 81.8% and 5-year survival was 75.0%. The infection-free survival at 1, 3, and 5 years was 87.5%, 81.8% and 62.5%, respectively. The overall survival and infection-free survival curves for Open repair, EVAR and SM FEVAR when compared using Log Rank (Mantel-Cox) test and did not show any statistically significant difference. CONCLUSIONS: Management of MAAA with selective use of open or endovascular repair, in combination with appropriate long-term antibiotic therapy, can achieve acceptable outcomes. The proposed protocol can aid as a guiding document for the management of MAAA but needs taking into consideration individual patient variability and local expertise.