Multicenter Comparative Analysis of Late Open Conversion in Patients With Adherence and Nonadherence to Instructions for Use Endovascular Aneurysm Repair.

PURPOSE: The widespread adoption of endovascular aneurysm repair (EVAR) as preferred treatment modality for abdominal aortic aneurysm (AAA) has enlarged the number of patients needing open surgical conversion (OSC). The relationship between adherence to Instructions For Use (IFU) and EVAR long-term outcomes remains controversial. The aim of this study is to compare preoperative differences and postoperative outcomes between EVAR patients not adjusted to IFU and adjusted to IFU who underwent OSC. METHODS: This multicenter retrospective study reviewed 33 explanted EVARs between January 2003 and December 2019 at 14 Vascular Units. Patients were included if OSC occurred >30 days after implantation and excluded if explantation was performed to treat an endograft infection, aortic dissection, or traumatic transections. Variables analyzed included baseline characteristics, adherence to IFU, implant and explant procedural details, secondary reinterventions, and postoperative outcomes. RESULTS: Fifteen explanted patients (15/33, 45.5%) were identified not accomplished to IFU (out-IFU) at initial EVAR vs 18 explanted patients adjusted (in-IFU). During follow-up, a mean of 1.73±1.2 secondary reinterventions were performed, with more type I endoleaks treated in the subgroup out-IFU: 16.7% vs 6.3% in-IFU patients and more type III endoleaks (8.3% vs 0%). Patients out-IFU had shorter mean interval from implant to explant: 47.60±28.8 months vs 71.17±48. Type II endoleak was the most frequent indication for explantation. Low-flow endoleaks (types II, IV, V) account for 44% of indications for OSC in subgroup of patients in-IFU, compared with 13.3% in patients out-IFU and high-flow endoleaks (types I and III) were the main indication for patients out-IFU (33.3% vs 16.7% in-IFU). Total endograft explantation was performed in 57.5% of cases (19/33) and more suprarenal clamping was required in the subgroup out-IFU. Overall, 30-day mortality rate was 12.1% (4/33): 20% for patients out-IFU and 5.6% in-IFU. CONCLUSIONS: In our experience, type II endoleak is the most common indication for conversion and differences have been found between patients treated outside IFU with explantation taking place earlier during follow-up, mainly due to high-flow endoleaks and with higher mortality in comparison with patients adjusted to IFU. Ongoing research is required to delve into these differences.

A randomized controlled noninferiority trial comparing radiofrequency with stripping and conservative hemodynamic cure for venous insufficiency technique for insufficiency of the great saphenous vein.

OBJECTIVE: The quality of available evidence regarding new minimally invasive techniques to abolish great saphenous vein reflux is moderate. The present study assessed whether radiofrequency ablation (RFA) was noninferior to high ligation and stripping (HLS) and conservative hemodynamic cure for venous insufficiency (CHIVA) for clinical and ultrasound recurrence at 2 years in patients with primary varicose veins (VVs) due to great saphenous vein (GSV) insufficiency. METHODS: We performed a randomized, single-center, open-label, controlled, noninferiority trial to compare RFA and 2 surgical techniques for the treatment of primary VVs due to GSV insufficiency. The noninferiority margin was set at 15% for absolute differences. Patients aged >18 years with primary VVs and GSV incompetence, with or without clinical symptoms, C2 to C6 CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) clinical class, and GSV diameter >4 mm were randomized with a 1:1:1 ratio to RFA, HLS, or CHIVA. The rate of clinical recurrence at 24 months was the primary endpoint and was analyzed using a delta noninferiority margin of 15%. Ultrasound recurrence, safety, and quality of life were secondary endpoints. RESULTS: From December 2012 to June 2015, 225 limbs had been randomized to RFA, HLS, or CHIVA (n = 74, n = 75, and n = 76). Clinical follow-up and Doppler ultrasound examinations were performed at 1 week and 1, 6, 12, and 24 months postoperatively. No differences in postoperative complications or pain were observed among the three groups. RFA was noninferior to HLS and CHIVA for clinical recurrence at 24 months, with an estimated difference in recurrence of 3% (95% confidence interval [CI], -4.8% to 10.7%; noninferiority P = .002) and -7% (95% CI, -17% to 3%; P < .001), respectively. For ultrasound recurrence, RFA was noninferior to CHIVA, with an estimated difference of -34% (95% CI, -47% to -20%; noninferiority P < .001) at 24 months. However, noninferiority could not be demonstrated compared with HLS (5.9%; 95% CI, -4.1 to 15.9; P = .073). No differences were found in quality of life among the three groups. CONCLUSIONS: RFA was shown to be noninferior in terms of clinical recurrence to HLS and CHIVA in the treatment of VVs due to GSV insufficiency.

National Diagnostic Reference Levels for Endovascular Aneurysm Repair and Optimisation Strategies.

OBJECTIVE: The International Commission on Radiological Protection (ICRP) has highlighted the large number of medical specialties using fluoroscopy outside imaging departments without programmes of radiation protection (RP) for patients and staff. Vascular surgery is one of these specialties and endovascular aneurysm repair (EVAR) is one of the most challenging procedures requiring RP guidance and optimisation actions. The recent European Directive on Basic Safety Standards requires the use and regular update of diagnostic reference levels (DRL) for interventional procedures. The objective of the study was to know the doses of patients undergoing EVAR with mobile Xray systems and with hybrid rooms (fixed Xray systems), to obtain national DRLs and suggest optimisation actions. METHODS: The Spanish Chapter of Endovascular Surgery launched a national survey that involved hospitals for 10 autonomous communities representing the 77% of the Spanish population (46.7 million inhabitants). Patient dose values from mobile Xray systems were available from nine hospitals (sample of 165 EVAR procedures) and data from hybrid rooms, from seven hospitals, with dosimetric data from 123 procedures. The initial national DRLs have been obtained, as the third quartile of the median values from the different centres involved in the survey. RESULTS: The proposed national DRLs are 278 Gy cm2 for hybrid rooms and 87 Gy cm2 for mobile Xray systems, and for cumulative air kerma (cumulative AK) at the patient entrance reference point, 1403 mGy for hybrid rooms, and 292 mGy for mobile systems. CONCLUSION: An audit of patient doses for EVAR procedures to identify optimised imaging protocol strategies is needed. It is also appropriate to evaluate the diagnostic information required for EVAR procedures. The increase by a factor of 3.2 (for kerma area product) and 4.8 (for cumulative AK) in the DRLs needs to be justified when the procedures are performed in the hybrid rooms rather than with mobile Xray systems.

Registry of Valvular and Vascular Allograft Transplants in the Autonomous Community of Catalonia, Spain (ReVAC): Design of the Registry.

BACKGROUND: In recent years, there have been significant changes in the perception of valvular and vascular allograft transplants. Despite the constant evolution of the field of transplant and the involvement of multiple surgical specialties, there is not an official registry for administrative and clinical control. This study aims to design a registry of vascular and valvular allograft transplantation in Catalonia, Spain (ReVAC). MATERIALS AND METHODS: Three consecutive focal groups were designed. Focal groups established administrative, technical, and clinical requirements of ReVAC. ReVAC included patients with a transplanted cryopreserved vascular segment or cardiac valves that were distributed by Catalan tissue banks to public and private hospitals in Catalonia. Ten hospitals were involved in this study. Data were collected on 380 patients between January 1995 and November 2015. RESULTS: The project resulted in the completion of a growing platform available online. ReVAC was divided into the following 3 levels: patient-related, surgery-related, and transplant-related data. Online access is available through the website of applications of the "Generalitat de Catalunya." CONCLUSION: ReVAC has been useful for administrative and clinical control of transplants in Catalonia. Currently, data related to outcomes of arterial allografts are available, reinforcing the current guideline-supported indications, as well as opening a window for further analysis and guideline creation.

Could Preoperative Neck Anatomy Influence Follow-up of EVAR?

BACKGROUND: The aim of the study was to assess the clinical utility of strict CT scan surveillance after endovascular abdominal aneurysm repair (EVAR) and evaluate whether the anatomy of abdominal aortic aneurysm (AAA) neck (favorable/hostile) influences regular imaging control. METHODS: A retrospective study of AAA patients who underwent EVAR with aortobi-iliac endoprostheses during 2006-2013 was conducted. Exclusion criteria included other types of devices. Variables analyzed were technical and clinical success, morbimortality, complications (such as endoleaks, sac enlargement), reinterventions, reintervention-free survival, and survival rate. Preoperative CT scans were performed and repeated at 1, 6 (in selective cases), 12, and 24 months postoperatively. Patients were divided into two groups according to preoperative anatomic characteristics: group I (favorable neck) and group II (hostile neck: angle > 60°, length < 15 mm, diameter > 28 mm, and calcification or circumference thrombus ≥50%). RESULTS: A total of 127 patients with AAA (96.8% male) were included in the study. The mean age of the patients was 75.9 years (range: 51-90 years). The mean AAA diameter was 62.1 mm. Hostile neck was found in 52 patients (40.9%). The technical and clinical success rate was 100% and 30-day mortality was 0.8%. The reintervention-free survival rate was 97.6%, 96.1%, and 93.7% and the survival rate was 97.6%, 96.9%, and 91.3%, during follow-up at 6, 12, and 24 months, respectively. Accumulated complications in proximal sealing occurred in 0%, 0%, and 1.6% in group I and 1.9%, 6.1%, and 7.7% in group II at 1, 12, and 24 months, respectively. Type II endoleaks occurred in 24.3%, 14.3%, and 11.4% in group I and 9.8%, 6.3%, and 6.8% in group II at 1, 12, and 24 months, respectively. No increased diameter was detected at 6 and 12 months. No differences were observed in reinterventions and mortality rate depending on anatomy. CONCLUSIONS: CT scans performed at 6 and 12 months postoperatively did not detect complications or need for reintervention in patients with favorable necks, even in the presence of endoleaks type II, and could therefore be omitted. Hostile necks may compromise proximal sealing and require regular imaging follow-ups.

Ruptura aórtica abdominal espontánea por úlcera penetrante tratada mediante reparación endovascular / Treatment of spontaneous abdominal aortic rupture due to a penetrating ulcer by means of endovascular repair

Introducción. La úlcera penetrante aórtica se define como una lesión arterioesclerosa con ulceración de la íntima y media aórticas, con ruptura de la lámina elástica interna, que se localiza predominantemente en la aorta torácica; es infrecuente su localización en la aorta abdominal. La llegada de las técnicas endovasculares ha incrementado las posibilidades terapéuticas. Caso clínico. Varón de 77 años, que acudió a Urgencias por dolor abdominal y anemia progresiva. La tomografía computarizada mostraba una ruptura aórtica abdominal con fuga de contraste 1 cm por debajo del ostium de la arteria renal derecha, así como la presencia de pseudoaneurisma de 5 cm en el espacio subdiafragmático. Como tratamiento de urgencia se decidió la colocación de una endoprótesis aortouniilíaca con oclusor ilíaco derecho y bypass femorofemoral izquierda-derecha, excluyendo la arteria renal izquierda para el correcto sellado proximal. El paciente se estabilizó hemodinámicamente, pero falleció a los 97 días por fallo multiorgánico. La autopsia confirmó la correcta situación de la endoprótesis, sin fugas e integrada en la pared aórtica. Conclusión. La úlcera penetrante aórtica abdominal es una lesión potencialmente mortal por el elevado riesgo de ruptura. El tratamiento endoluminal constituye una opción terapéutica menos agresiva, que puede disminuir las tasas de morbimortalidad en pacientes de alto riesgo

Introduction. A penetrating aortic ulcer is defined as an arteriosclerotic lesion with ulceration of the aortic tunica intima and media, with rupture of the internal elastic lamina, which is predominantly located in the thoracic aorta; it is infrequently found in the abdominal aorta. The advent of endovascular techniques has brought with it an increase in the number of therapeutic possibilities available. Case report. A 77-year-old male, who visited the Emergency department with abdominal pain and progressive anaemia. A computerised tomography scan revealed the presence of a rupture of the abdominal aorta with contrast leak 1 cm below the ostium of the right renal artery, together with the presence of a 5-cm pseudoaneurysm in the subdiaphragmatic space. Emergency treatment consisted in placement of an aortouniiliac stent with right iliac occlusion and left-right femorofemoral bypass, with exclusion of the left renal artery in order to achieve proper proximal sealing. The patient became haemodynamically stable, but died at 97 days due to multiple organ failure; the autopsy confirmed correct location of the stent, with no leaks, and it was integrated within the wall of the aorta. Conclusions. Penetrating abdominal aortic ulcer is a potentially fatal lesion due to the high risk of rupture. Endoluminal treatment constitutes a less aggressive therapeutic option that can lower the morbidity and mortality rates in high risk patients

Estudio de calidad de vida en pacientes afectos de isquemia crítica a medio plazo / Study of the medium term quality of life in patients with critical ischaemia

Introducción. El tratamiento de la isquemia crítica de extremidades inferiores tiene por finalidad el salvamento de la extremidad, la resolución de los síntomas y la mejora en la calidad de vida. Objetivo. Determinar diferencias en términos de calidad de vida en pacientes con isquemia crítica y que se revascularizan con éxito (grupo I), y aquellos sin posibilidad revascularizadora, amputados o con trombosis del bypass durante el seguimiento (grupo II). Pacientes y métodos. Seleccionamos una muestra aleatoria de 48 pacientes con isquemia crítica. Aplicamos el test SF-36 al primer y segundo año y evaluamos la permeabilidad, salvamento de la extremidad y la mortalidad. Resultados. La supervivencia global al primer y segundo año fue del 79% y 56%, respectivamente, con una permeabilidad para la cirugía del 94% y 86% y un salvamento de extremidad del 100%, excluidas las amputaciones primarias. No encontramos diferencias en ninguno dominio del SF-36 entre ambos grupos al primer y segundo año. La media de supervivencia global fue de 26 meses. Conclusiones. La calidad de vida a medio plazo en los pacientes revascularizados no difiere de los no revascularizados, amputados o con trombosis del bypass. El dolor y la limitación física así como los múltiples factores de comorbilidad presentes en estos pacientes implican un pronóstico pobre en términos de calidad de vida a pesar de los tratamientos realizados

Introduction. The purpose of treatment of critical ischaemia of the lower extremities is to salvage the limb, resolve the symptoms and improve the patient’s quality of life. Aim. To determine the differences, as far as quality of life is concerned, between patients with critical ischaemia who undergo successful revascularisation (group I) and those who cannot be revascularised, have suffered amputation or in whom a thrombosis was observed in the bypass during follow-up (group II). Patients and methods. We selected a random sample of 48 patients with critical ischaemia. The SF-36 test was applied at one and two years and patency, limb salvage and mortality rates were evaluated. Results. Overall survival at one and two years was 79% and 56%, respectively, with 94% and 86% patency for surgery, and a limb salvage rate of 100%, excluding primary amputations. No differences were found between the two groups at one and two years in any of the areas of the SF-36. Overall mean survival time was 26 months. Conclusions. There is no difference between the medium term quality of life in revascularised patients and those who have not undergone revascularisation, have suffered amputation or who have a thrombosed bypass. The pain and physical limitations, as well as the multiple comorbidity factors that these patients have, imply a poor prognosis in terms of quality of life despite the treatments that are carried out