Predictive Parameters of Type 1A Endoleak for Elective Endovascular Aortic Repair: A Single-Center Experience.

BACKGROUND: One of the most important factors that affects the success of Endovascular Aortic Repair (EVAR) treatment is the morphology of the neck of the aneurysm. Today, EVAR can be performed even in patients who do not meet the Instruction For Use criteria with hostile neck risk factors; thanks to the developing experience and technology. Our aim in this study was to determine risk factors for Type 1a endoleaks in patients who underwent EVAR and predictive factors for Type 1a endoleaks in patients with combinations of these risk factors. METHODS: Patients who underwent elective EVAR for infrarenal abdominal aortic aneurysm in our medical center between July 2016 and January 2021 were enrolled. Of these 244 patients, 180 patients with documented preoperative and postoperative computed tomographic angiography results and a follow-up of at least 1 year were included in the study. The Mann-Whitney U test and Student's t-test were used to assess the relationship between nominal data and numerical values, and the t-test and Wilcoxon test were used to compare dependent groups. Logistic regression analysis was performed to model risk factors associated with endoleaks. RESULTS: The results showed that a neck length less than 15 mm increased the development of type 1a endoleak by 10.4 times (P < 0.001). Furthermore, a neck diameter more than 28 mm increased the development of type 1a endoleak by 21.9 times (P = 0.04). A conical neck structure (gradual neck dilation > 2 mm) increased the development of type 1a endoleaks 4.8 times (P = 0.04). The presence of calcification (> 150 Hounsfield Unit and > 2 mm) in the neck increased the risk of type 1a endoleaks fourfold (P = 0.04). Hostile neck parameters were analyzed and patients with only 1 parameter (n = 69) had a 7.2% type 1a endoleak rate, while patients with 2 parameters (n = 15) had 26.6% and patients with more than 2 parameters (n = 11) had 45.5% type 1a endoleak rate. CONCLUSIONS: Morphologic features of the neck structure of the aneurysm are among the most important parameters that affect the success of EVAR treatment. Alternative treatments should be considered in patients with more than 1 unfavorable neck parameter.

The impact of large proximal aortic neck on endovascular aneurysm repair outcomes.

Background: This study aims to investigate the effect of large proximal aortic neck diameter on post-endovascular aneurysm repair clinical outcomes. Methods: A total of 180 patients (168 males, 12 females; mean age: 69.9±7.4 years; range, 46 to 88 years) who underwent elective endovascular aneurysm repair between June 2016 and September 2021 were retrospectively analyzed. According to the proximal infrarenal aortic neck diameter, the patients were divided into two groups: Group 1 (<25 mm; normal aortic neck) and Group 2 (≥25 mm; pre-aneurysmatic aortic neck). Patient characteristics, proximal infrarenal aortic neck diameter measurements with computed tomography angiography, and clinical outcomes were recorded. The primary endpoint was to assess post-endovascular aneurysm repair aortic neck dilatation, mortality, endoleaks, overall survival, type 1a endoleaks-free survival, and eventfree survival regarding the groups. Results: There was no statistically significant difference in early mortality (p=0.55) and type 1a endoleak incidence between the groups (p=0.55). In Group 1, the mean change in diameter A (proximal infrarenal level) was 2.89±1.74 mm (p=0.01), and it was 2.31±2.1 mm in diameter B (proximal pre-aneurysm-sac level) (p=0.01). The mean change in Group 2 was 2.8±3.4 mm for diameter A (p<0.01) and 2.22±2.3 mm for diameter B (p<0.01). Aortic neck dilatation rates were similar between the groups (p=0.82 for diameter A; p=0.78 for diameter B). The five-year survival, event-free survival, and type 1a endoleak-free survival were also similar (p=0.54, p=0.26, p=0.24, respectively). Conclusion: Our study results showed that patients with <25 mm and ≥25-mm aortic neck diameters had similar mid-term results and aortic neck dilatation ratio. Endovascular aneurysm repair outcomes can be improved with careful patient and graft selection, and early intervention for complications.

Carbon Dioxide Guided Endovascular Aortic Aneurysm Repair in Impaired Renal Function: Propensity Score Matched Study.

OBJECTIVE: Carbon dioxide (CO2) is the preferred contrast agent in patients with impaired renal function and or contrast allergy and, particularly, in patients who require large volumes of contrast for complex endovascular procedures. In this study, the aim was to clarify the possible protective effects of CO2 guided endovascular aneurysm repair (EVAR) for patients with impaired renal function by propensity score matching. METHODS: A retrospective analysis of the database was performed for 324 patients having EVAR between January 2019 and January 2022. A total of 34 patients treated with CO2 guided EVAR were evaluated. This cohort was matched for age, sex, pre-operative serum creatinine levels and glomerular filtration rate (GFR) levels and specific comorbidities to obtain homogeneous groups that included only patients with impaired renal function (eGFR < 60 mL/min/1.73m2). The primary endpoint was to compare the decrease in eGFR from baseline and development of contrast induced nephropathy (CIN) using propensity score matching. Secondary endpoints were the need for renal replacement therapy, other peri-procedural morbidity and mortality. RESULTS: Thirty-one patients (9.6%) of the total population developed CIN. There was no difference in the rate of CIN development between the standard EVAR group and the CO2 guided EVAR group in the unmatched population (10% vs. 3%, p = .15). After matching, the decrease in eGFR values after the procedure was more pronounced for the standard EVAR group (from 44 to 40 mL/min/1.73m2, interaction p = .034). Meanwhile, CIN development was more frequent for the standard EVAR group (24% vs. 3%, p = .027). In matched patients, early death did not differ between the groups (5.9% vs. 0, p = .15) CONCLUSION: Patients with impaired renal function are at higher risk of CIN after an endovascular procedure. CO2 guided EVAR is a safe, effective, and feasible treatment option, especially for patients with impaired renal function. CO2 guided EVAR may be a protective measure for contrast induced nephropathy.

Early and Midterm Outcomes of Endovascular Treatment in Arterial Manifestations of Vascular Behcet Disease.

BACKGROUND: Behcet's disease (BD), originally described by Hulusi Behcet in 1937, is a chronic relapsing inflammatory process of an immunologic syndrome and the involvement of the vascular system is called Vasculo-Behcet disease (VBD). This is a retrospective study evaluating 21 patients diagnosed with VBD who underwent endovascular treatment. METHODS: This single-center study was conducted between January 2016 and January 2022. Early and mid-term endovascular outcomes of a total of 21 patients (16 males, 5 females with a median age of 42 years; range, 31 to 46 years), with a diagnosis of VBD, who underwent endovascular arterial repair in our hospital, were retrospectively analyzed. Follow-ups were scheduled for the first and sixth postoperative months and every 6 months thereafter. For symptomatic patients, imaging studies and additional interventions were planned. The primary outcomes were a procedural success and a requirement for reintervention. Secondary outcomes were complications and all causes of mortality. RESULTS: Twenty-one patients underwent endovascular repair. In this study, 1 balloon-expandable stent for brachial artery aneurysm (4,8%), 1 viabahn graft for femoral artery aneurysm (4,8%), 2 tube endograft for ruptured iliac artery aneurysm (9,5%), 1 tube endograft (Thoracic endovascular aortic repair [TEVAR]) insertion at the aortic bifurcation for infrarenal abdominal aortic occlusion (4,8%), 1 chimney-TEVAR for saccular arcus thoracic aortic aneurysm (TAA) (4,8%) and 7 TEVAR for saccular TAA (33,3%), 1 EVAR for an intact and symptomatic infrarenal abdominal aortic aneurysm (AAA) (4,8%), 1 EVAR (aorto-uniiliac) for ruptured iliac artery aneurysm (4,8%), and 6 EVAR for ruptured AAA (28,5%) were deployed. The technical success rate was 100% with a mean follow-up period of 50. 4 ± 10.7 months (8-66 months). The mean aneurysm diameter was 10,7 ± 53 mm. In the follow-up period, 3 patients presented with a hematoma at the insertion site of the sheath (14.3%). There were no early mortalities. Three patients required reintervention (14,3%); 1 of these underwent open surgical repair due to a pseudoaneurysm of the access site (4,8%). The Kaplan-Meier analysis revealed freedom from reintervention rate as 94,1 ± 5,7% at 1 year, 85,6 ± 9,7% at 3 years, and 68,4 ± 17,1% at 5 years. CONCLUSIONS: Awareness of the BD especially for vascular involvements in young ages is lifesaving. Endovascular therapy with proper medical treatment seems to be the treatment of choice according to the early and midterm successful results with low morbidity and mortality.

Incidentally discovered cold hemagglutinins within autologous blood bag and cardioplegia line in a patient with a recent history of COVID-19 undergoing coronary artery surgery.

INTRODUCTION: Cold agglutinin disease (CAD) is a rare autoimmune disorder characterized by destruction (hemolysis) of erythrocytes. In CAD, autoantibodies that cause agglutination at temperature of optimum +3-+4 ℃ degree cause symptoms. It is known that CAD often occurs after viral infections. Also, it has been reported in case reports that COVID-19 disease can cause CAD. CASE REPORT: 46-year-old male patient with a history of diabetes mellitus and hypertension presented to outpatient clinic in our department to have CABG surgery. He recovered from COVID-19 disease 1.5 months ago. Cardiopulmonary bypass was initiated and the cross-clamp was placed and antegrade Delnido cardioplegia solution was started to be given at +4 ℃. It was observed that the cardioplegia line was agglutinated. On the other hand, it was seen that the autologous blood taken by the anesthesiologist was also agglutinated and formed air bubbles and became unusable. X-clamp was removed and the heart rhythm recovered. The patient was consulted to hematology during postoperative intensive care follow-ups. The cold agglutinin test performed at of +4 ℃ was reported as positive. In this case, we associated the CAD with covid-19 for three main reasons. First one, the patient's complaints about CAD started after COVID-19 disease. Secondly, in the national health archive, the patient's pre-COVID-19 blood tests were completely normal but it was seen that LDH increased and RBC-HCT incompatibility started after COVID-19. As the third, when we search the literature, we have seen the COVID-19 related CAD in many case reports published by hematologists. CONCLUSION: With the rare cold agglutinin disease, it seems that we will encounter it more often after the COVID-19 pandemic. Except for deep hypothermia, the most important problem is seen during cardioplegia administration. Therefore, non-blood cardioplegia can be lifesaving.

Glasgow Aneurysm Score: a predictor of long-term mortality following endovascular repair of abdominal aortic aneurysm?

BACKGROUND: To evaluate the value of Glasgow Aneurysm Score (GAS) in predicting long-term mortality and survival in patients who have undergone endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). METHODS: A retrospective single-center study of 257 patients with non-ruptured AAA undergoing EVAR between January 2013 and 2021. GAS scores were compared between the survivors (group 1) and the long-term mortality (group 2) groups. Cox regression analysis was used to determine independent predictors of late mortality. Receiver operating characteristic curve (ROC) analysis was used to determine the optimum cut-off values of GAS values to determine the effect on late-mortality. Survival analysis was conducted using Kaplan-Meier. RESULTS: The study included 257 patients with a mean age of 69.75 ± 7.75 (46-92), who underwent EVAR due to AAA. Average follow up period was 18.98 ± 22.84 months (0-88). Fourty-five (17.8%) mortalities occured during long-term follow-up. A past medical history of cancer resulted in a 2.5 fold increase in risk of long-term mortality (OR: 2.52, 95% CI 1.10-5.76; p = 0.029). GAS values were higher in group 2 compared to group 1 (81.02 ± 10.33 vs. 73.73 ± 10.46; p < 0.001). The area under the ROC curve for GAS was 0.682 and the GAS cut-off value was 77.5 (specificity 64%, p < 0.001). The mortality rates in patients with GAS < 77.5 and GAS > 77.5 were: 12.8% and 24.8% respectively (p = 0.014). Every 10 point increase in GAS resulted in approximately a 2 fold increase in risk of long-term mortality (OR: 1.8, 95% CI 1.3-2.5; p < 0.001). Five year survival rates in patients with GAS < 77.5 and > 77.5 were 75.7% and 61.7%, respectively (p = 0.013). CONCLUSIONS: The findings of our study suggests that an increase in GAS score may predict long-term mortality. In addition, the mortality rates in patients above the GAS cut-off value almost doubled compared to those below. Furthermore, the presence of a past history of cancer resulted in a 2.5 fold increase in long-term mortality risk. Addition of cancer to the GAS scoring system may be considered in future studies. Further studies are necessary to consolidate these findings.

Early and late-term follow-up results of patients diagnosed with aortic aneurysm or aortic dissection with aortic regurgitation undergoing aortic valve repair or valve-sparing aortic surgery

Abstract Introduction: Valve-reimplantation and remodelling techniques used in aortic reconstruction provide successful early, mid, and long-term results. We present our early and late-term experience with 110 patients with aortic regurgitation (AR) who underwent aortic valve repair (AVr) or valve-sparing aortic root surgeries (VSARS) due to aortic dissection or aortic aneurysm. Methods: Nine hundred eighty-two patients who underwent aneurysm or dissection surgery and aortic valve surgery between April 1997 and January 2017 were analysed using the patient database. A total of 110 patients with AR who underwent AVr or VSARS due to aortic dissection or aortic aneurysm were included in the study. Results: In the postoperative period, a decrease was observed in AR compared to the preoperative period (P<0.001); there was an increase in postoperative ejection fraction (EF) compared to the preoperative values (P<0.005) and a significant decrease in postoperative left ventricle diameters compared to the preoperative values (P<0.001). Kaplan-Meier analysis revealed one, two, four, and five-year freedom from moderate-severe AR as 95%, 91%, 87%, and 70%, respectively. Freedom from reoperation in one, two, and five years were 97.9%, 93.6%, and 81%, respectively. Eight patients (7.4%) underwent AVr during follow-up. Out of the remaining 100 patients, 13 (12%) had minimum AR, 52 (48%) had 1st-2nd degree AR, and 35 (32%) had 2nd-3rd degree AR during follow-up. Conclusion: For the purpose of maintaining the native valve tissue, preserving the EF and the left ventricular end-diastolic diameter, valve-sparing surgeries should be preferred for appropriate patients.

Early and Late-Term Follow-Up Results of Patients Diagnosed with Aortic Aneurysm or Aortic Dissection with Aortic Regurgitation Undergoing Aortic Valve Repair or Valve-Sparing Aortic Surgery.

INTRODUCTION: Valve-reimplantation and remodelling techniques used in aortic reconstruction provide successful early, mid, and long-term results. We present our early and late-term experience with 110 patients with aortic regurgitation (AR) who underwent aortic valve repair (AVr) or valve-sparing aortic root surgeries (VSARS) due to aortic dissection or aortic aneurysm. METHODS: Nine hundred eighty-two patients who underwent aneurysm or dissection surgery and aortic valve surgery between April 1997 and January 2017 were analysed using the patient database. A total of 110 patients with AR who underwent AVr or VSARS due to aortic dissection or aortic aneurysm were included in the study. RESULTS: In the postoperative period, a decrease was observed in AR compared to the preoperative period (P<0.001); there was an increase in postoperative ejection fraction (EF) compared to the preoperative values (P<0.005) and a significant decrease in postoperative left ventricle diameters compared to the preoperative values (P<0.001). Kaplan-Meier analysis revealed one, two, four, and five-year freedom from moderate-severe AR as 95%, 91%, 87%, and 70%, respectively. Freedom from reoperation in one, two, and five years were 97.9%, 93.6%, and 81%, respectively. Eight patients (7.4%) underwent AVr during follow-up. Out of the remaining 100 patients, 13 (12%) had minimum AR, 52 (48%) had 1st-2nd degree AR, and 35 (32%) had 2nd-3rd degree AR during follow-up. CONCLUSION: For the purpose of maintaining the native valve tissue, preserving the EF and the left ventricular end-diastolic diameter, valve-sparing surgeries should be preferred for appropriate patients.