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Purpose: This study aims to investigate whether routine screening for silent pulmonary embolism (PE) can be justified in patients with deep vein thrombosis (DVT). Materials and Methods: We retrospectively analyzed the medical records of 201 patients with lower-extremity DVT admitted to the vascular surgery department of a single tertiary university center between 2019 and 2023. All patients underwent clinical evaluation, basic laboratory exams, a whole-leg colored duplex ultrasound, and a computed tomography pulmonary angiography (CTPA), to screen for an occult, underlying PE. Results: The overall incidence of silent PE was 48.8%. The median admission D-dimer level was significantly higher in patients with silent PE than in those without PE (9.60 vs. 5.51 mg/L, P=0.001). A D-dimer value ≥5.14 mg/L was discriminant for predicting silent PE, with a sensitivity of 68.2% and a specificity of 59.3%. Silent PE was significantly more common on the right side, with the embolus located at the main pulmonary, lobar, segmental, and subsegmental arteries in 29.6%, 32.7%, 20.4%, and 17.3%, respectively. A higher incidence of occult PE was observed in patients with iliofemoral DVT (P=0.037), particularly when the thrombus extended to the inferior vena cava (P=0.003). Moreover, iliofemoral DVT was associated with a larger size and a more proximal location of the embolus (P=0.041). Multivariate logistic regression showed that male sex (odds ratio [OR]=2.46, 95% confidence interval [CI]: 1.39-3.53; P=0.026), cancer (OR=2.76, 95% CI: 1.45-4.07; P=0.017), previous venous thromboembolism (VTE) history (OR=2.67, 95% CI: 1.33-4.01; P=0.022), D-dimer value ≥5.14 mg/L (OR=2.24, 95% CI: 1.10-3.38; P=0.033), iliofemoral DVT (OR=2.13, 95% CI: 1.19-3.07; P=0.041), and thrombus extension to the IVC (OR=2.95, 95% CI: 1.43-4.47; P=0.009) served as independent predictors for silent PE. Conclusion: A high incidence of silent PE was observed in patients with lower-extremity DVT. Screening of patients with DVT who have the aforementioned predictive risk factors using CTPA for silent PE may be needed and justified for the efficient management of VTE and its long-term complications.
RESUMO
Endovascular aortic aneurysm sealing (EVAS) with the Nellix endograft was initially considered a groundbreaking and acceptable alternative to conventional endovascular aortic aneurysm repair, with encouraging initial results. However, long-term follow-up has revealed a high incidence of endograft-related complications, such as caudal migration and type Ia endoleaks, indicating the need for reintervention. Managing failed EVAS remains challenging and is an ongoing topic of discussion, especially for high-risk patients. We describe a 70-year-old female who initially underwent EVAS with a Nellix endograft and presented after 5 years of follow-up with caudal endograft migration and a type Ia endoleak. The patient was treated with endovascular implantation of an Altura stent-graft, a relatively new low-profile device with a similar double stent configuration. Device migration and endoleaks were undetectable at 12 months of follow-up, suggesting that the Altura might offer a safe and efficient approach in cases of Nellix proximal failure.
RESUMO
PURPOSE: To measure the long-term proximal aortic neck dilatation (AND) after elective endovascular aortic aneurysm repair (EVAR) with a variety of contemporary, third-generation, endograft devices. MATERIALS AND METHODS: This is a noninterventional prospective cohort study of 157 patients that underwent standard EVAR with self-expanding abdominal endografts. Patients' recruitment lasted from 2013 to 2017, and postoperative follow-up was up to 5 years. A computed tomography angiography (CTA) was performed at the first month and then at 1, 2, and 5 years. Proximal aortic neck's (PAN) basic morphological characteristics (diameter, length, angulation) were measured based on the analysis of CTA in a standardized fashion. Neck-related adverse events, such as migration, endoleak or rupture, and reinterventions were recorded. RESULTS: Significant straightening of the PAN was evident even in the first-month CTA with concurrent neck shortening that became significant at 5 years. Both the suprarenal aorta and the PAN significantly dilated overtime, with PAN dilating more progressively. Mean neck dilatation at the juxtarenal level was 0.8±0.4 mm at 1 year, 1.8±0.8 mm at 2 years, and 3.9±1.7 mm at 5 years, with a mean neck dilatation rate of 0.07 mm/month overall. The incidence of AND ≥2.5 mm was 37.2% at 2 years and 58.1% at 5 years after EVAR and was considered important (≥5 mm) in 11.5% of patients at 2 years and 30.6% of patients at 5 years. A multivariate analysis performed showed that the endograft oversizing, the preoperative neck diameter, and the preoperative abdominal aortic aneurysm sac diameter served as independent predictors of AND at 5 years. At the 5-year follow-up, 8 late type Ia endoleaks (6.5%) and 7 caudal migrations (5.6%) were identified, while no late ruptures were reported. In total, 11 late endovascular reinterventions (8.9%) were performed. Overall, proximal neck-related adverse outcomes (5/7 migrations and 5/8 endoleaks) and reinterventions (7/11) were significantly associated with the presence of important late AND. CONCLUSION: Proximal AND after EVAR is common. It can influence the long-term durability of proximal endograft fixation and is significantly associated with adverse outcomes, often leading to reinterventions. A systemic and extended surveillance protocol is needed for maintenance of good long-term results. CLINICAL IMPACT: This is a thorough and systematic analysis of the long-term geometric remodeling of the proximal aortic neck after EVAR, that highlights the importance of a strict, and extended surveillance protocol for maintenance of good long-term results of EVAR.
