Perioperative Outcomes for Abdominal Aortic Aneurysm Repair Based on Aneurysm Diameter.

BACKGROUND: Guidelines from the Society for Vascular Surgery recommend elective repair in asymptomatic patients with an abdominal aortic aneurysm (AAA) only if their diameter is greater than or equal to 5.5 cm, yet smaller ones are routinely repaired. This study aims to evaluate perioperative outcomes based on aneurysm size at the time of repair. METHODS: Male patients who underwent elective endovascular aneurysm repair (EVAR) or open abdominal aneurysm repair (OAAR) repair of an infrarenal AAA were abstracted from 2011 to 2015 Targeted National Surgical Quality Improvement Program (NSQIP) database. Patients with symptoms or with aneurysmal extension into the visceral or iliac vessels were excluded. Outcomes of open versus endovascular repair were reported, with multivariate analyses to identify factors associated with the decision to repair AAA ≤5.4 cm. RESULTS: A total of 2115 (90.9%) patients underwent EVAR, while 213 (9.1%) underwent OAAR. The mean diameter in patients who underwent OAAR was 6.1 cm (interquartile range [IQR]: 5.2-6.1 cm) versus 5.7 cm (IQR: 5.2-6.0 cm) for EVAR. However, in 42.5% of EVAR and 32.8% of OAAR patients, the diameter of the AAA was 5.4 cm or less. The group undergoing repair of AAA ≤5.4 cm was younger compared to the larger AAA group (71.9 vs 73.9 years; P < .0001). Patients older than 80 years were less likely to have a repair of AAA measuring ≤5.4 cm (odds ratio [OR] = 0.45, 95% confidence interval [CI] = 0.30-0.65). Additionally, patients who underwent EVAR were more likely to have AAA measuring ≤5.4 cm repaired compared to those who underwent OAAR (OR = 1.62, 95% CI = 1.19-2.21). There were no differences in perioperative morbidity or mortality between the groups. CONCLUSION: There were no differences in perioperative outcomes after AAA repair, independent of aneurysm diameter. We found a higher likelihood of repairing AAA ≤5.4 cm in younger patients who were more likely to have been repaired with EVAR. Patients older than 80 years were less likely to undergo small AAA repair.

False-negative upper extremity ultrasound in the initial evaluation of patients with suspected subclavian vein thrombosis due to thoracic outlet syndrome (Paget-Schroetter syndrome).

OBJECTIVE: To assess the utilization and consequences of upper extremity Duplex ultrasound in the initial diagnostic evaluation of patients with suspected subclavian vein (SCV) thrombosis and venous thoracic outlet syndrome (VTOS). METHODS: A retrospective single-center review was conducted for patients that underwent primary surgical treatment for VTOS between 2008 and 2017, in whom an upper extremity ultrasound had been performed as the initial diagnostic test (n = 214). Clinical and treatment characteristics were compared between patients with positive and false-negative ultrasound studies. RESULTS: There were 122 men (57%) and 92 women (43%) that had presented with spontaneous idiopathic arm swelling, including 28 (13%) with proven pulmonary embolism, at a mean age of 30.7 ± 0.8 years (range 14-69). Upper extremity ultrasound had been performed 23.8 ± 12.2 days after the onset of symptoms, with confirmation of axillary-SCV thrombosis in 169 patients (79%) and negative results in 45 (21%). Of the false-negative ultrasound study reports, only 8 (18%) acknowledged limitations in visualizing the central SCV. Definitive diagnostic imaging (DDI) had been obtained by upper extremity venography in 175 (82%), computed tomography angiography in 24 (11%), and magnetic resonance angiography in 15 (7%), with 142 (66%) undergoing catheter-directed axillary-SCV thrombolysis. The mean interval between initial ultrasound and DDI was 48.9 ± 14.2 days with no significant difference between groups, but patients with a positive ultrasound were more likely to have DDI within 48 hours than those with a false-negative ultrasound (44% vs 24%; P = .02). At the time of surgical treatment, the SCV was widely patent following paraclavicular decompression and external venolysis alone in 74 patients (35%). Patch angioplasty was performed for focal SCV stenosis in 76 (36%) and bypass graft reconstruction for long-segment axillary-SCV occlusion in 63 (29%). Patients with false-negative initial ultrasound studies were significantly more likely to require SCV bypass reconstruction than those with a positive ultrasound (44% vs 25%; P = .02). CONCLUSIONS: Duplex ultrasound has significant limitations in the initial evaluation of patients with suspected SCV thrombosis, with false-negative results in 21% of patients with proven VTOS. This is rarely acknowledged in ultrasound reports, but false-negative ultrasound studies have the potential to delay definitive imaging, thrombolysis, and further treatment for VTOS. Initial false-negative ultrasound results are associated with progressive thrombus extension and a more frequent need for SCV bypass reconstruction at the time of surgical treatment.

MR-based attenuation correction for PET/MRI neurological studies with continuous-valued attenuation coefficients for bone through a conversion from R2* to CT-Hounsfield units.

AIM: MR-based correction for photon attenuation in PET/MRI remains challenging, particularly for neurological applications requiring quantitation of data. Existing methods are either not sufficiently accurate or are limited by the computation time required. The goal of this study was to develop an MR-based attenuation correction method that accurately separates bone tissue from air and provides continuous-valued attenuation coefficients for bone. MATERIALS AND METHODS: PET/MRI and CT datasets were obtained from 98 subjects (mean age [±SD]: 66yrs [±9.8], 57 females) using an IRB-approved protocol and with informed consent. Subjects were injected with 352±29MBq of (18)F-Florbetapir tracer, and PET acquisitions were begun either immediately or 50min after injection. CT images of the head were acquired separately using a PET/CT system. Dual echo ultrashort echo-time (UTE) images and two-point Dixon images were acquired. Regions of air were segmented via a threshold of the voxel-wise multiplicative inverse of the UTE echo 1 image. Regions of bone were segmented via a threshold of the R2* image computed from the UTE echo 1 and UTE echo 2 images. Regions of fat and soft tissue were segmented using fat and water images decomposed from the Dixon images. Air, fat, and soft tissue were assigned linear attenuation coefficients (LACs) of 0, 0.092, and 0.1cm(-1), respectively. LACs for bone were derived from a regression analysis between corresponding R2* and CT values. PET images were reconstructed using the gold standard CT method and the proposed CAR-RiDR method. RESULTS: The RiDR segmentation method produces mean Dice coefficient±SD across subjects of 0.75±0.05 for bone and 0.60±0.08 for air. The CAR model for bone LACs greatly improves accuracy in estimating CT values (28.2%±3.0 mean error) compared to the use of a constant CT value (46.9%±5.8, p<10(-6)). Finally, the CAR-RiDR method provides a low whole-brain mean absolute percent-error (MAPE±SD) in PET reconstructions across subjects of 2.55%±0.86. Regional PET errors were also low and ranged from 0.88% to 3.79% in 24 brain ROIs. CONCLUSION: We propose an MR-based attenuation correction method (CAR-RiDR) for quantitative PET neurological imaging. The proposed method employs UTE and Dixon images and consists of two novel components: 1) accurate segmentation of air and bone using the inverse of the UTE1 image and the R2* image, respectively and 2) estimation of continuous LAC values for bone using a regression between R2* and CT-Hounsfield units. From our analysis, we conclude that the proposed method closely approaches (<3% error) the gold standard CT-scaled method in PET reconstruction accuracy.

Probabilistic Air Segmentation and Sparse Regression Estimated Pseudo CT for PET/MR Attenuation Correction.

PURPOSE: To develop a positron emission tomography (PET) attenuation correction method for brain PET/magnetic resonance (MR) imaging by estimating pseudo computed tomographic (CT) images from T1-weighted MR and atlas CT images. MATERIALS AND METHODS: In this institutional review board-approved and HIPAA-compliant study, PET/MR/CT images were acquired in 20 subjects after obtaining written consent. A probabilistic air segmentation and sparse regression (PASSR) method was developed for pseudo CT estimation. Air segmentation was performed with assistance from a probabilistic air map. For nonair regions, the pseudo CT numbers were estimated via sparse regression by using atlas MR patches. The mean absolute percentage error (MAPE) on PET images was computed as the normalized mean absolute difference in PET signal intensity between a method and the reference standard continuous CT attenuation correction method. Friedman analysis of variance and Wilcoxon matched-pairs tests were performed for statistical comparison of MAPE between the PASSR method and Dixon segmentation, CT segmentation, and population averaged CT atlas (mean atlas) methods. RESULTS: The PASSR method yielded a mean MAPE ± standard deviation of 2.42% ± 1.0, 3.28% ± 0.93, and 2.16% ± 1.75, respectively, in the whole brain, gray matter, and white matter, which were significantly lower than the Dixon, CT segmentation, and mean atlas values (P < .01). Moreover, 68.0% ± 16.5, 85.8% ± 12.9, and 96.0% ± 2.5 of whole-brain volume had within ±2%, ±5%, and ±10% percentage error by using PASSR, respectively, which was significantly higher than other methods (P < .01). CONCLUSION: PASSR outperformed the Dixon, CT segmentation, and mean atlas methods by reducing PET error owing to attenuation correction.

Society for Vascular Surgery (SVS) Vascular Registry evaluation of comparative effectiveness of carotid revascularization procedures stratified by Medicare age.

OBJECTIVE: Recent randomized controlled trials have shown that age significantly affects the outcome of carotid revascularization procedures. This study used data from the Society for Vascular Surgery Vascular Registry (VR) to report the influence of age on the comparative effectiveness of carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS: VR collects provider-reported data on patients using a Web-based database. Patients were stratified by age and symptoms. The primary end point was the composite outcome of death, stroke, or myocardial infarction (MI) at 30 days. RESULTS: As of December 7, 2010, there were 1347 CEA and 861 CAS patients aged < 65 years and 4169 CEA and 2536 CAS patients aged ≥ 65 years. CAS patients in both age groups were more likely to have a disease etiology of radiation or restenosis, be symptomatic, and have more cardiac comorbidities. In patients aged <65 years, the primary end point (5.23% CAS vs 3.56% CEA; P = .065) did not reach statistical significance. Subgroup analyses showed that CAS had a higher combined death/stroke/MI rate (4.44% vs 2.10%; P < .031) in asymptomatic patients but there was no difference in the symptomatic (6.00% vs 5.47%; P = .79) group. In patients aged ≥ 65 years, CEA had lower rates of death (0.91% vs 1.97%; P < .01), stroke (2.52% vs 4.89%; P < .01), and composite death/stroke/MI (4.27% vs 7.14%; P < .01). CEA in patients aged ≥ 65 years was associated with lower rates of the primary end point in symptomatic (5.27% vs 9.52%; P < .01) and asymptomatic (3.31% vs 5.27%; P < .01) subgroups. After risk adjustment, CAS patients aged ≥ 65 years were more likely to reach the primary end point. CONCLUSIONS: Compared with CEA, CAS resulted in inferior 30-day outcomes in symptomatic and asymptomatic patients aged ≥ 65 years. These findings do not support the widespread use of CAS in patients aged ≥ 65 years.

Outcomes of percutaneous endovascular intervention for type II endoleak with aneurysm expansion.

OBJECTIVE: Type II endoleak (T2EL) with aneurysm expansion is believed to place patients at risk for aneurysm-related mortality (ARM). Treatment with glue and/or coil embolization of the aneurysm sac, inferior mesenteric artery (IMA), and lumbar branches via translumbar or transarterial approaches has been utilized to ablate such endoleaks, and thus decrease ARM. We evaluated the midterm results of percutaneous endovascular treatment of T2EL with aneurysm expansion. METHODS: Single-institution, 5-year (January 2003 to August 2008) retrospective study of all endovascular interventions for T2EL with sac expansion. Blinded, independent review of all available pre- and post-T2EL intervention computed tomography (CT) scans was performed. Aneurysm sac maximal transverse diameters and aneurysm sac growth rates prior to and following T2EL intervention were analyzed. RESULTS: Forty-two patients (34 male, eight female; mean age, 75) underwent T2EL intervention at 26 ± 20 months after endovascular aneurysm repair (EVAR) and were subsequently followed for 23 ± 20 months. Seven out of 42 patients (17%) underwent repeat T2EL intervention. Interventions included 44 translumbar sac embolizations, and transcatheter embolizations of nine IMAs and seven lumbar/hypogastric arteries. Aneurysm diameter was 6.1 ± 1.6 cm at EVAR, 6.6 ± 1.5 cm at initial T2EL treatment, and 6.9 ± 1.7 cm at last follow-up. There were no significant differences in the rates of aneurysm sac growth pre- and post-T2EL treatment. At last follow-up imaging, recurrent or persistent T2EL was noted in 72% of patients. Of 42 patients, nine (21%) received operative endoluminal correction of occult type I or type III endoleaks that were diagnosed during the T2EL angiographic intervention. There were no aneurysm ruptures or ARMs during follow-up; overall mortality for the 5-year study period was 24%. CONCLUSIONS: In this series, percutaneous endovascular intervention for type II endoleak with aneurysm sac growth does not appear to alter the rate of aneurysm sac growth, and the majority of patients display persistent/recurrent endoleak. However, diagnostic angiographic evaluation may reveal unexpected type I and III endoleaks and is therefore recommended for all patients with T2EL and sac growth. While coil and glue embolization of aneurysm sac and selected branch vessels does not appear to yield benefit in our series, the diagnosis and subsequent definitive treatment of previously occult type I and III endoleaks may explain the absence of delayed rupture and ARM in our series.

Population-based analysis of inpatient vascular procedures and predicting future workload and implications for training.

OBJECTIVE: The purpose of this study was to analyze the trend in inpatient vascular procedures in the United States over the past decade and predict the future demand for vascular surgeons. METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample was queried to determine the weighted national estimates of inpatient vascular procedures performed on adult patients (age ≥ 18) between 1997 and 2008. Using population estimates from the United States Census Bureau, the per capita rates of inpatient procedures were calculated for age-specific groups (18-64 years, 65-84 years, and ≥ 85 years). The change in per capita rates over the past decade along with population forecasts were used to predict future workload. RESULTS: There was a net increase of 22% from 971,046 inpatient vascular procedures for all adults in 1997 to 1,188,332 in 2008. During the same time period, the adult population increased by 16% from 198 to 230 million. The age-stratified per capita rates of all vascular procedures were +21% for age 18 to 64; -4% for age 65 to 84; and +18% for age ≥ 85. This resulted in a net increase of 5% (490 to 515 procedures per 100,000 capita) in the per capita rate for all adults. Based on the assumption that trends in age-specific rates remain constant, there is a predicted inpatient workload increase (compared to 2008) of 18% by 2015, 34% by 2020, and 72% by 2030. The vascular workload is predicted to more than double by the year 2040. CONCLUSIONS: Despite a conservative approach of using a population-based analysis of only inpatient procedures, there is a dramatic increase in the predicted vascular workload for the future. The vascular surgery training process will need to adapt to ensure an adequate number of fellowship-trained vascular surgeons is available to provide quality vascular care in the future.

Use of a bifurcated endovascular graft for treatment of endograft migration with major endoleak.

The purpose of this study was to describe the use of a bifurcated endovascular graft to treat endograft migration with major endoleaks. We present four patients who presented at a mean of 72.0 months after their initial endovascular abdominal aortic aneurysm repair. Three patients had type I endoleaks resulting from proximal attachment failure and graft migration. A fourth patient had separation of a proximal aortic cuff from a migrated main body device resulting in a type III endoleak. All were treated with a bifurcated Zenith (Cook Medical Incorporated, Bloomington, IN, USA) endovascular graft. There was 100% technical success with no perioperative complications. On follow-up, one patient died of unrelated causes at five months. The mean survival for the remaining three patients was 37 months. In conclusion, treatment with a bifurcated Zenith endograft has advantages over the use of an aortic cuff or aortouniiliac reconstruction. To perform this technique, there must be a sufficient distance between the proximal landing zone and the flow divider of the migrated endograft to allow for deployment of the Zenith device. While there remain limitations in its applicability, the use of a bifurcated endovascular graft is a viable alternative for endovascular salvage in treatment of endograft migration with major endoleaks.

Long-term outcomes of endovascular aneurysm repair for challenging aortic necks using the Talent endograft.

The aim of the present paper is to evaluate the long-term outcomes of endovascular aneurysm repair (EVAR) for challenging aortic necks. Subgroup analyses were performed on 156 patients from the prospective multicenter Talent eLPS (enhanced Low Profile Stent Graft System) trial. Patients with high-risk aortic necks (length < 15 mm or diameter ≥28 mm) were compared with the remaining patients. Patients with high-risk (n = 86) and low-risk necks (n = 70) had similar age and gender distribution. Despite similar prevalences of co-morbidities, the high-risk group had higher Society for Vascular Surgery scores. The high-risk group also had larger maximum aneurysm diameters (56.6 versus 53.0 mm, P < 0.02). There were lower freedoms from major adverse events (MAEs) for the high-risk group at 30 days (84.9 versus 95.7%; P < 0.04) and 365 days (73.4 versus 89.2%; P = 0.02). Effectiveness endpoints at 12 m showed no significant differences. Freedom from all-cause mortality at 30 days (96.5 versus 100%) and aneurysm-related mortality at 365 days (96.0 versus 100%) were similar. At five years, there were no differences in endoleaks or change in aneurysm diameter. All migrations occurred in the high-risk group. The five-year freedom from aneurysm-related mortality for the high- and low-risk groups was 93.2 and 100%, respectively. In conclusion, despite a higher rate of MAEs within the first year and higher migration rates at five years, EVAR in aneurysms with challenging aortic necks can be treated with acceptable long-term results.

Society for Vascular Surgery Vascular Registry evaluation of stent cell design on carotid artery stenting outcomes.

OBJECTIVE: The Society for Vascular Surgery (SVS) Vascular Registry (VR) collects data on outcomes of carotid endarterectomy and carotid artery stenting (CAS). The purpose of this study was to evaluate the impact of open vs closed cell stent design on the in-hospital and 30-day outcome of CAS. METHODS: The VR collects provider-reported data on patients using a Web-based database. Data were analyzed both in-hospital and at 30 days postprocedure. The primary outcome is combined death/stroke/myocardial infarction (MI). RESULTS: As of October 14, 2009, there were 4337 CAS with discharge data and 2397 with 30-day data. Open cell stents (OPEN) were used in 3451 patients (79.6%), and closed cell stents (CLOSED) were used in 866 patients (20.4%). Baseline demographics showed no differences in age, gender, race, and ethnicity. However, the OPEN group had more patients with atherosclerosis (74.5% vs 67.4%; P = .0003) as the etiology of carotid artery disease. The OPEN group also had a higher prevalence of preprocedural stroke (25.8% vs 21.4%; P = .0079), chronic obstructive pulmonary disease (COPD; 21.0% vs 17.6%; P = .0277), cardiac arrhythmia (14.7% vs 11.4%; P = .0108), valvular heart disease (7.4% vs 3.7%; P < .0001), peripheral vascular disease (PVD; 40.0% vs 35.3%; P = .0109), and smoking history (59.0% vs 54.1%; P = .0085). There are no statistically significant differences in the in-hospital or 30-day outcomes between the OPEN and CLOSED patients. Further subgroup analyses demonstrated symptomatic patients had a higher event rate than the asymptomatic cohort in both the OPEN and CLOSED groups. Among symptomatic patients, the OPEN patients had a lower (0.43% vs 1.41%; P = .0349) rate of in-hospital mortality with no difference in stroke or transient ischemic attack (TIA). There were no differences in 30-day event rates. In asymptomatic patients, there were also no statistically significant differences between the OPEN and CLOSED groups. After risk adjustment, there remained no statistically significant differences between groups of the primary endpoint (death/stroke/MI) during in-hospital or 30 days. CONCLUSION: In-hospital and 30-day outcomes after CAS were not significantly influenced by stent cell design. Symptomatic patients had higher adverse event rates compared to the asymptomatic cohort. As there is no current evidence of differential outcome between the use of open and closed cell stents, physicians should continue to use approved stent platforms based on criteria other than stent cell design.

Midterm outcomes of the Zenith Renu AAA Ancillary Graft.

OBJECTIVE: The Zenith Renu abdominal aortic aneurysm (AAA) Ancillary Graft (Cook Medical Inc, Bloomington, Ind) provides active proximal fixation for treatment of pre-existing endografts with failed or failing proximal fixation or seal. The purpose of this study was to evaluate the midterm outcomes of treatment with this device. METHODS: From September 2005 to November 2006, a prospective, nonrandomized, multicenter, postmarket registry was utilized to collect physician experiences from 151 cases (89 converters and 62 main body extensions) at 95 institutions. Preoperative indications and procedural and postimplantation outcomes were collected and analyzed. Technical success and clinical success were determined as defined by the Society of Vascular Surgery reporting standards. RESULTS: Patients were predominantly male (87%) with a mean age of 77 years. The interval between the original endograft implantation to Renu treatment was 43.4 ± 18.7 months. The indications for treatment were endoleak (n = 111), migration (n = 136), or both (n = 94). Technical success was 98.0% with two cases of intraoperative conversion and one case of persistent type IA endoleak. The median follow-up for the cohort was 45.0 months (range, 0-56 months; interquartile range, 25.0 months). Overall, 32 cases had treatment failures that included at least one of the following: death (n = 5), type I/III endoleak (n = 18), graft infection (n = 1), thrombosis (n = 1), aneurysm enlargement >5 mm (n = 9), rupture (n = 4), conversion (n = 9, with 7 after 30 days), and migration (n = 1). Overall, the clinical success for the entire cohort during the follow-up period was 78.8% (119/151). CONCLUSIONS: The postmarket registry data confirm that the Zenith Renu AAA Ancillary Graft can be used to treat endovascular repairs that failed due to proximal attachment failures. The salvage treatment with the Renu device had high technical success rate and resulted in clinical success in a majority of patients (78.8%). While failed endovascular repairs can be salvaged, a clinical failure in one of five patients still emphasizes the importance of patient and device selection during initial endovascular aneurysm repair to ensure durable success.

Outcome of endovascular repair of small and large abdominal aortic aneurysms.

BACKGROUND: To evaluate the outcomes of endovascular aneurysm repair (EVAR) in patients with small (≤5.4 cm) and large (≥5.5 cm) abdominal aortic aneurysms (AAAs). METHOD: Data for this study were obtained from the prospective, nonrandomized, multicenter Talent enhanced Low Profile Stent trial that enrolled patients between February 2002 and April 2003. A total of 156 patients with adequate preoperative imaging were identified for this study. Subgroup analyses were performed for patients with small (≤5.4 cm) and large (≥5.5 cm) AAAs. Demographics, aneurysm morphology, and perioperative endpoints were assessed. Safety and effectiveness endpoints were evaluated at 30 days, 1 year, and 5 years postprocedure. RESULTS: Patients with small AAAs (n = 85) had similar age, gender, and medical risk profile compared with those for larger AAAs (n = 71). The proximal aortic necks in small AAAs were longer (24.7 mm vs. 20.7 mm, p = 0.05), less angulated (27.2° vs. 34.2°, p = 0.01), and smaller (24.6 mm vs. 26.1 mm, p = 0.01). Patients with small AAAs spent less time in intensive care (8.1 hour vs. 26.3 hour, p = 0.03); however, other perioperative endpoints were similar. Although the group with small AAAs had a statistically significant higher rate of successful aneurysm treatment (96.8% vs. 84.9%, p = 0.04), no difference was observed in all other effectiveness endpoints at 12 months. No differences in freedom from major adverse events at 30 days and 365 days were reported. At 5 years, no differences in rates of migration, endoleaks, change in aneurysm diameter, or freedom from aneurysm-related mortality were found. Further subgroup analyses segregating patients with very small (≤5.0 cm, n = 55), small (5.1-5.4 cm, n = 30), and larger (≥5.5 cm) AAAs also showed no statistically significant differences in postoperative outcomes. CONCLUSIONS: In a prospective clinical trial setting with long-term follow-up, patients with small (≤5.4 cm) AAAs had aortic neck characteristics which were more favorable for EVAR. Despite these anatomic differences, clinical outcomes were similar to patients with large AAAs. Thus, we conclude that EVAR for small AAA should not be routinely recommended for patients on the basis of the assumption of improved outcomes.

Hybrid repair of distal arch aortic aneurysms: endovascular elephant trunk completion.

BACKGROUND: Traditional open repair of distal arch aortic aneurysms requires a two-stage procedure associated with significant morbidity and mortality. The introduction of thoracic endovascular aneurysm repair has created a less invasive option to complete the second stage of the repair after proximal elephant trunk creation. The present study reports a series of patients treated with a combined open proximal and endovascular distal repair of distal arch aortic aneurysms. METHODS: A retrospective review was undertaken at a university medical center. All patients treated with the hybrid approach were identified. The patients were evaluated for demographics, preoperative imaging, technical success, postoperative complications, length of hospital stay, need for secondary intervention, and overall survival. RESULTS: A total of 10 patients (3 men, mean age: 67.5 years) were identified during a 4-year period between August 2005 and July 2009. All patients were treated electively and the mean maximum aneurysm diameter was 70.8 mm. Of the 10 patients, four had undergone previous thoracotomy (three aortic repair, one pulmonary resection for malignancy) and all were deemed at prohibitive risk for open second-stage surgery. The first three patients had staged reconstruction with delayed endovascular intervention through retrograde arterial access. The more recent seven patients underwent single-stage repair with endograft delivery through an antegrade ascending aortic access. Technical success was achieved in all cases. No perioperative paraplegias or strokes were reported. One patient had successful endovascular treatment of a type IB endoleak at 38 months. Another had an enlarging thoracoabdominal aneurysm resulting in a type IB endoleak which was detected at 43 months. There was one death within 30 days after the procedure. The remaining nine patients are all alive, with a mean survival of 35.1 months (range: 8-53) after surgery. CONCLUSIONS: The hybrid approach to treatment of distal arch aortic aneurysms is safe and serves as a viable alternative to conventional open repair. Less technically challenging, avoidance of a second surgery as well as elimination of the possibility of becoming lost to follow-up, or interval mortality have led us to consider a single-stage repair using an antegrade approach as the preferred option.

A 5-year comparison of EVAR for large and small aortic necks.

PURPOSE: To compare the long-term outcomes of endovascular aneurysm repair (EVAR) using the Talent endograft for abdominal aortic aneurysms (AAAs) with large and small aortic necks. METHODS: Data on 156 patients (142 men; mean age 74.1 years, range 41-89) with adequate preoperative imaging were obtained from the prospective, nonrandomized, multicenter Talent eLPS trial, which enrolled patients from February 2002 to April 2003. Subgroup analyses were performed for AAAs with a large aortic neck diameter (≥28 mm; n=53, group 1) and those with smaller necks (<28 mm; n=103, group 2). Safety and effectiveness endpoints were evaluated at 30 days, 1 year, and 5 years post procedure. RESULTS: Patients in both groups had similar gender and risk factor profiles. However, group 1 was significantly older (mean age 76.5 versus 72.9 years; p<0.01). Aside from neck diameter, the 2 groups had similar mean neck length and angulation. Group 1 also had a larger maximum aneurysm diameter (mean 58.2 versus 53.4 mm; p<0.01). At 1 year, the 2 groups had similar effectiveness endpoint results. There was a significantly lower freedom from major adverse events (MAEs) for group 1 at 30 days (79.2% versus 95.1%; p<0.01). While this trend continued to 1 year, the difference lost statistical significance (72.0% versus 85.1%; p=0.08). Freedom from all-cause mortality at 30 days (94.4% versus 100%; p<0.04) and aneurysm-related death at 1 year (93.3 versus 100%; p<0.04) also was significantly lower for group 1. At 5 years, there were no significant differences in the rates of endoleaks or aneurysm changes. The 5-year rates for freedom from aneurysm-related mortality for groups 1 and 2 were 91.2% and 98.7% (p=NS), respectively. There were 5 instances of migration in this study, all occurring in group 1 patients. CONCLUSION: AAAs with aortic necks ≥28 mm can be treated with endovascular devices with acceptable results at 5 years. However, these patients have a higher rate of MAEs within the first year and higher migration rates at 5 years. In addition, they have a lower freedom from all-cause mortality at 30 days and aneurysm-related death at 1 year. Careful patient selection, accurate device deployment, and continued follow-up are necessary to optimize long-term results in this patient population.

A 5-year evaluation using the talent endovascular graft for endovascular aneurysm repair in short aortic necks.

BACKGROUND: Although endovascular aneurysm repair has been shown to be an effective way to treat abdominal aortic aneurysm (AAA), certain anatomic characteristics such as a short aortic neck, limit its applicability. Initially, commercially available devices were approved only for the treatment of AAA with an aortic neck length ≥ 15 mm. The purpose of this study was to evaluate the outcomes of the recently approved Talent endograft for AAAs with a short aortic neck length (10-15 mm). METHOD: Data were obtained from the prospective, nonrandomized, multicenter Talent enhanced Low Profile Stent Graft System trial which enrolled patients between February 2002 and April 2003. A total of 154 patients with adequate preoperative imaging were identified for this study. Subgroup analyses were performed for AAA with 10-15 mm aortic neck and those with >15 mm neck. Safety and effectiveness endpoints were evaluated at 30 days, 1 year, and 5 years postprocedure. RESULTS: Patients treated with aortic neck lengths of 10-15 mm (n = 35) and those with >15 mm (n = 102) had similar age, gender, and risk factor profile. Both groups had similar preoperative aneurysm morphology in terms of maximum aneurysm size, degree of neck angulation, or proximal neck diameter. There were no statistically significant differences in freedom from major adverse events and mortality rates at 30 and 365 days. Similarly, there was no difference in the effectiveness endpoints at 12 months. At 5 years, there was no difference in migration rate, endoleaks, or change in aneurysm diameter from baseline. In addition, there is no difference in freedom from aneurysm-related mortality (94% vs. 99%). CONCLUSIONS: AAAs with short aortic necks (10-15 mm) and otherwise suitable anatomy for endovascular repair can be safely and effectively treated with the Talent endograft with excellent 1 and 5 year outcomes.

Long-term outcome of endovascular popliteal artery aneurysm repair.

BACKGROUND: Popliteal artery aneurysms have traditionally been repaired with an open surgical approach. However, endovascular popliteal artery repair (EVPAR) has been used in selected patients because of its less invasive nature. In this report, we present our long-term outcomes for EVPAR. METHODS: Retrospective review of all patients who underwent EVPAR at a single academic institution between September 2002 and March 2006. These patients were evaluated for patency, need for secondary intervention, amputation-free survival, and overall survival. RESULTS: A total of 15 limbs in 13 patients were treated with EVPAR during the study period. All EVPAR were performed using the Viabahn(®) endoprostheses, with an average of 1.67 stents per limb. The mean age of the patients was 74.6 years (range, 66-84). Technical success was achieved in 100% and all limbs had initial postoperative ankle-arm indices of ≥ 1.0. Mean duration of follow-up was 54 months (range, 42-70). Two patients died of unrelated causes at 3 and 38 months with intact limbs, and one patient was lost to follow-up. Two limbs developed type I or III endoleaks, and were successfully treated with additional endovascular stent placement, resulting in a primary patency rate of 84.6% and secondary patency rate of 100%. There were no instances of limb loss during the follow-up period, yielding both amputation-free survival and overall survival rates of 85.7%. CONCLUSIONS: Long-term follow-up of this cohort of EVPAR patients suggests that in selected patients, this is a durable technique, capable of achieving excellent patency rates and limb preservation. Further large-scale clinical trials are warranted to help define optimal candidates for this technique.

Arterial access for thoracic endograft placement.

BACKGROUND: Endovascular repair of thoracic aortic disease continues to evolve since FDA approval of the first thoracic endograft in the United States in March 2005. Certain anatomic characteristics, including adequacy of arterial access, remain a significant limiting factor in thoracic endovascular repair. In clinical trials evaluating thoracic endografts, vascular access complications occurred in >20% of cases. The purpose of this study is to evaluate the arterial access and the selective use of the ascending aorta for thoracic endograft placement. METHOD: A retrospective review was performed for patients who underwent thoracic endograft placement between May 2005 and April 2009 (4 years since FDA approval of the first thoracic endograft). Patient records were reviewed for the indication for the procedure, type of arterial access, technical success, and access-related complications. RESULTS: Seventy-nine thoracic endografts were placed during the study period. The indications for endograft placement included 53 aneurysms, 10 traumatic lesions, 6 endoleaks, 4 dissections, 3 penetrating ulcers, 2 bleeding aortic fistulas, and 1 thoracic diverticulum. Retrograde access was used in 70 cases (89%): 60 femoral (76%) and 10 aortoiliac (13%). Antegrade access through a 10-mm polyester graft anastomosed to the ascending aorta was used in nine cases (11%). These procedures included endograft placement with proximal elephant trunk creation in six cases, endograft-alone in two cases, and combination with proximal arch reconstruction/debranching in one case. There was 100% technical success for all cases. The overall access-related complication rate was 6%. There were no complications with antegrade access through the ascending aorta or with aortoiliac access. There were five complications in the femoral access group (three iliac artery dissection, one iliac artery injury, and one femoral artery injury). CONCLUSIONS: Access selection is an important part of the preoperative planning of endovascular procedures. Choosing the most appropriate access for a patient will decrease the access-associated complication rate. In addition, selected patients with poor aortoiliac access and those that require debranching or elephant trunk procedures may benefit from antegrade access.

Use of a surgeon-modified branched thoracic endograft to preserve an aortorenal bypass during treatment of an intercostal patch aneurysm.

A 72-year-old man presented with thoracic pain. Nine years earlier, a descending aortic dissection with aneurysmal degeneration had been treated by thoracoabdominal aortic graft placement with reimplantation of a visceral patch and an intercostal patch. A separate left aortorenal bypass had also been performed with the bypass originating from the thoracic portion of the graft. He now presents with a 7.2-cm intercostal patch aneurysm in the aortic segment containing the origin of the patent aortorenal bypass. We present the use of a surgeon-modified branched thoracic endograft to salvage an aortorenal bypass originating in a thoracic aneurysm after previous open thoracoabdominal aortic aneurysm repair.